Battling diseases on all fronts

Sunday Star, April 17, 2011

By LOH FOON FONG

foonfong@thestar.com.my

There is a need for a multi-pronged strategy to make Malaysians take their health more seriously.

SEAH Boo Hee, 42, was diagnosed with insulin-dependent diabetes when he was 16. His kidneys failed three years ago and he now suffers bleeding in the eye due to his diabetic condition. “If I had known the severe consequences of diabetes, I would have tried harder to change my diet,” he says.

Seah admits that as a teenager, he did not know much about good diet. “My normal diet,' like most teenagers, was fast food and sometimes mamak food at night.” He also did not realise he would lose his kidneys when a doctor told him about protein leakage in his urine five years ago, he adds.

“The doctor didn't explain to me what it meant and I thought nothing was wrong because I felt fine. If I was told that it was an early sign of kidney failure, I would have done everything I could to save my kidneys.” Being saddled with many health problems, Seah who is 185cm tall and weighs 94kg is finding it hard to get a job.

Dr Ikram: ‘If they live until 65 but get diabetes at 25, that’s 40 years of diabetes. A lot of complications can set in’

“If employers know that you need dialysis and have to be away from work three days a week, your chances of getting of a job is zero,” he says. Currently jobless, this graduate used to play tennis and squash and travelled a lot. He has had to give all this up because he is not allowed to drink too much water due to his failed kidneys.

Seah's mother died of diabetic coma and one of his older sisters is also diabetic. Many patients, like Seah, do not fully understand the severe consequences of diabetic complications until one of their organs fail or when traged y strikes. Nephrologist Dr S.S. Gill says many Malaysians think they are immune to these diseases. “They don't realise that it takes 20 to 30 years before they suffer from the effects,” he says.

Some even say they do not have chronic diseases although they are overweight. But as one ages, the risk of incidence will increase, he warns. “Our life span may now be longer, but it lacks quality.” According to endocrinologist Datuk Prof Dr Ikram Shah Ismail, one in five Malaysians is diabetic and three quarters of deaths related to diabetes are the result of heart attack.

“This is alarming,” says Dr Ikram, who is also dean of Universiti Malaya's Faculty of Medicine. In 1996, Health Ministry data showed that 8.9% of the population were diabetic and it was predicted to reach 10% in 2020. But by 2006, the figures had shot up to 14.9% and two years ago, it reached a high of 20%.

»My ‘normal diet’, like most teenagers, was fast food and sometimes mamak food at night« SEAH BOO HEE

Health Minister Datuk Seri Liow Tiong Laihas said the rise in chronic diseases is worrying. “Those getting chronic diseases are no longer in their 50s or older. Now, people as young as 30 or 40 are getting hypertension, heart attacks, diabetes and kidney failure. Many of these illnesses ca n be prevented,” he stresses.

He points out that the number of chronic kidney patients in the country has increased from 79 per million population in 2000 to 146 per million in 2009. The National Renal Registry reveals that the total number of patients on dialysis increased from 6,689 in 2000 to 21,159 in 2009, putting a serious strain on Malaysia's health resources.

Of these, 58% have diabetes. This puts Malaysia in the unenviable position of probably having the highest percentage of patients in the world with diabetes as the cause of end-stage kidney failure, according to Liow. Seah's case reflects three things. First, the need for doctors to talk to patients in layman's terms and help them understand the implications of their actions and their medical condition.

Secondly, parents and schools must introduce healthy diets and exercise to children from a young age; and thirdly, the whole machinery of society needs to be mobilised to support every individual in fighting chronic diseases.

Seah points out an important misconception diabetic patients tend to think that when they take medicine, everything will be all right. “They don't realise that if they don't take care of their diet and lifestyle, no medicine can prevent their organs from being damaged.”

Dr Ikram explains that although diabetes is an inherited disease, it does not mean it is unavoidable. “In the past, incidence of diabetes was low because people worked in the fields and they walked or cycled. Those with diabetic genes didn't become diabetic until much later in life, or totally avoided it.

“If they were supposed to get diabetes at 70, but died at 60, the diabetes did not appear in their lifetime.”

However, the life span is now longer and an unhealthy lifestyle has led those in their 20s or 30s to become diabetic, says Dr Ikram who believes that parents need to set good examples in their diet and also that schools should also provide healthier food options to children.

“You can imagine if they live until 65 but get diabetes at 25, that's 40 years of diabetes. A lot of complications can set in, like eye damage or kidney damage, and the quality of life will be poor.” Dr Ikram says people like to blame their parents for bad genes, but their lifestyle can determine whether they develop diabetes at the age of 30 or 70.

“For instance, many people say they cannot live without added sugar even when we tell them they are getting enough sugar from other food sources. People survived well without sugar in the past,” he says, adding that misplaced perception has also led many to see smoking as dangerous but do not consider their unhealthy diet as a problem. Losing weight and keeping oneself healthy, as many would attest, is a discipline in life that is almost unattainable for many.

“I try to bring down my weight but it's a struggle,” Seah, who is 16kg overweight, confesses. National Kidney Foundation chief executive officer Chua Hong Wee says even though Malaysians are now more affluent, their lifestyles have become worse and many are indulging in high-sugar and high-carbohydrate drinks and food, and eating late into the night.

“People are overeating, especially with easy access to food 24 hours a day. This poses a burden on kidneys because the organs have to work extra hard to remove waste,” he says. People must make it a life-long practice to reduce intake of sugar and salt, eat more healthy and balanced meals, and exercise but not many have the stamina to do the right thing continuously, he points out.

The dire situation needs to be tackled with drastic measures, and the Health Ministry has rightly adopted a multi-pronged approach. It adopted an “all-of-government” and “allof- society” approach against non-communicable diseases (NCD) this year, which called for the collaboration of 11 ministries, the local authorities, the media, professional bodies, private sectors, communities and NGOs. As Malaysians eat out a lot, the quality of food at food outlets has to be given top-most attention.

This is where the Health Promotion Board has to step up efforts to make food manufacturers and operators offer healthier options. As pointed out in a conference in Kuala Lumpur recently, the Singapore Health Promotion Board, for instance, had encouraged a manufacturer to produce whole grain noodles that incorporate 10% of whole grain, half the recommended daily requirement.

Dr Ikram also feels the authorities should restrict the opening of food outlets to 10pm. “People should go home and sleep,” he says, adding that 24-hour food outlets are a relatively new phenomenon and which we managed to live without in the past.

Liow points out that Malaysians are consuming too much oil (2.1kg per person per month) and the Ministry is studying its impact on their health. Dr Gill says awareness must be created continuously.

Finland, for instance, had one of the highest rate of heart diseases but managed to bring down the numbers after 30 years, he says. Efforts have to start with the young, he stresses. “It's tough getting people to change but we have to keep trying.”

Most Malaysians lack exercise, which can easily solve half of our health problems. In Australia, the local council provides gymnasiums for the public to use for free, he adds Dr Ikram has called on local councils to provide clean and safe parks to attract people to go there. Companies too can motivate their staff members to exercise together and promote better work relations, he says.

Understanding human behaviour or attitude why people tend to be addicted to eating bad food and not healthy food is a mind boggling matter.

Universiti Malaya Centre of Addiction Sciences director Professor Dr Mohd Hussain Habil says the Government should give more grants for such studies and on whether excessive eating habits should be treated as a form of addiction or psychological issue. “This is a relatively new concept that should be explored since obesity is an important public health issue,” he says.

The American Journal of Psychiatry points out in one of its issues that standard interventions based on promoting lifestyle changes to reduce excessive food consumption and increase physical activity are effective but people could not sustain the efforts.

One in three Americans is obese, and this increases risk for cardiovascular disease, diabetes, cancer, and other diseases, resulting in annual healthcare costs conservatively estimated for the US at $70bil to $100bil ((RM218bil to RM302bil) a year as well as reductions in life expectancy by five to 20 years.

In South Korea, naturally-derived sugar from fruit sources are often used instead of processed sugar and much of their meals, snacks and desserts contain little salt and sugar and are free of artificial colourings or additives.

The Koreans, who are very nationalistic about their food that is mostly made up of kimchi, vegetables, seaweed and fish, really take their health into their own hands.

Malaysians should emulate the Koreans as the battle against chronic diseases must be fought by the whole nation. Only when all citizens begin to take charge of their health and moti vate others to do likewise will they be healed of self-inflicted diseases.

Source: http://thestar.com.my/news/story.asp?file=/2011/4/17/nation/20110417072313&sec=nation

Others

• The Star Editorial Awards - monthly mention

Best Story of the month - November 2010 - Houseman glut

Saturday November 27, 2010

Too many new doctors and too few hospitals to train them

By LOH FOON FONG
foonfong@thestar.com.my

PETALING JAYA: The number of medical housemen undergoing clinical training in most government hospitals has increased and this has given rise to concern that they may not get sufficient experience.

With new medical schools opening up locally and lower fees being offered at new institutions abroad, around 4,000 Malaysian medical students are expected to graduate annually from 350 universities all over the world in the coming years.

Senior Hospital Kuala Lumpur (HKL) consultant physician Datuk Dr S. Jeyaindran said each specialist was supervising four times as many housemen compared to a decade ago.

“Five years ago, one houseman looked after 10 patients in hospital wards at any one time but now it is one to four patients,” said Dr Jeyaindran, who is HKL department of medicine head and national head for medicine at the Health Ministry.

“The concern is that these interns are seeing fewer patients and hence, have fewer opportunities to carry out adequate procedures. In some hospitals, there are more housemen than patients.”

Dr Jeyaindran said they were not only concerned about the increase in numbers but also their attitude.

“Some lack responsibility towards their patients,” he said, adding that there were also those who did not know how to give an accurate diagnosis and relied too much on investigative tools instead of clinical skills and getting the proper patient history.

Malaysian Medical Council ethics committee chairman Datuk Dr Abdul Hamid Abdul Kadir said several specialists had expressed concern about the large numbers and training hospitals were finding it difficult to cope.

“In the past, it was five housemen in each department but now it could be 20 to 30 for each department,” he said, adding that some specialists were overburdened by the workload.

Health Minister Datuk Seri Liow Tiong Lai said the ministry was aware of the issue and would be increasing the number of training hospitals.

He said the ideal ratio should be one specialist supervising five housemen with one houseman taking care of 14 hospital beds depending on discipline.

There were 38 hospitals providing training to more than 3,058 housemen last year.

However, the number increased to the current 6,253 housemen since the ministry increased the duration of housemanship from one year to two.

“This led to most hospitals, including those in Sabah and Sarawak, having an excess of housemen,” he said.

Hospitals that were chosen must be able to cater to six areas in which housemen need training – medical, surgical, paediatrics, obstetrics and gynaecology, orthopaedic and accident, and emergency, he said.

Liow also said that they would be getting 58 contract specialists from Egypt, India and Pakistan next month to help supervise housemen and reduce the burden of the specialists now.

He also said that the ministry had taken steps to overcome the lack of experience among housemen by making training compulsory for two years instead of one.

Source: http://thestar.com.my/news/story.asp?file=/2010/11/27/nation/7509809&sec=nation

Best Feature of the month - December 2010 - Cleaning house

Sunday December 12, 2010

Cleaning house

By RICHARD LIM and LOH FOON FONG
educate@thestar.com.my

Concerns persist regarding the quality of medical graduates and the Government is preparing a number of initiatives to finetune the system.

HOW hard is it to tell the difference between a sleeping patient and a cyanosed one who is on course to meet his maker?

Observing the simple rise and fall of one’s chest would be a good start. Checking for a pulse would be another and observing that the patient has turned blue is an absolute must.

However, the obvious did not happen in the case of one Pak Abu, who was deemed to be sleeping by house officers.

Fortunately, an observant doctor on his last rounds came into the picture and Pak Abu was resuscitated.

The three house officers in charge, who graduated from Russian and Ukrainian universities, were reprimanded for negligence, and things went from bad to worse when it was discovered that they did not know the basics of resuscitation or what an oxygen face mask was.

Mohamed Khaled says agents are not appointed or recognised by the ministry.

The doctor who blogged about this was among the many who had been highlighting the urgent need to ensure the quality of housemen vis-a-vis their increasing numbers which was highlighted in The Star’s front page report two weeks ago.

The phenomena stemmed from the large number of medical students – at home and abroad – as well as the Health Ministry’s decision to increase the duration of housemanship, from one year to two years.

An overcrowding of housemen has occured at some of the nation’s 39 training hospitals, and senior Hospital Kuala Lumpur (HKL) consultant physician Datuk Dr S. Jeyaindran said that a houseman would normally look after four patients now — down from 10 five years ago.

“The concern is that these interns are seeing fewer patients and hence, have fewer opportunities to carry out adequate procedures.

“In some hospitals, there are more housemen than patients,” said Dr Jeyaindran, who is also the head of medicine at the Health Ministry.

Liow says housemen would be trained at six new hospitals.

Different worlds

Following the influx of housemen, senior doctors have sounded the alarm that an over-emphasis on numbers could come at the expense of quality.

They were particularly concerned with medical graduates from Russia, Ukraine, Indonesia and India, whom they said lacked core knowledge and basic expertise in treating patients.

Although all medicals schools should share a universal purpose - saving lives - differences in pedagogy and clinical procedures put some graduates on the back foot when they return to Malaysia.

And this was the case for a Ukrainian university graduate who endured a torrid time in his attachment at a local hospital.

“Many doctors were unhappy that we (housemen from Russia and Ukraine) don’t follow the British system,” he said.

“The terminologies we used were not accepted although they denote the same meaning. This led some to develop the misconception that graduates of Eastern European medical schools lack the necessary knowledge to perform,” he said.

A source said that the emphasis on the study of diseases was also different to a certain extent, as medical schools in a particular country would naturally cater to the common ailments of its citizens.

Dr Quek has blogged about quality concerns at private medical schools in Malaysia.

He added that housemen who studied medicine in Eastern Europe lack exposure to tropical diseases and had to brush up on their theoretical and clinical knowledge upon their return.

If there are already so many problems with accredited foreign universities, what should we expect of unaccredited institutions — with poor living conditions, inadequate facilities and lecturers of suspect quality?

And there is the eyebrow raising issue of foreign medical schools accepting students with Arts backgrounds.

The problem is not a new one. In 2005, the Crimea State Medical University was de-listed by the Malaysian Medical Council (MMC) for doing exactly that, among other things.

Giving credit where credit is due, the MMC acted upon complaints by whistle-blowers and the problem was rectified.

Task forces were sent out to check on errant medical schools overseas and warnings were served to foreign medical schools which were found wanting.

Shady dealings

The adage goes, “When the going gets tough, the tough get going.” But who are the tough and where do they go?

A houseman who spoke to The Star on condition of anonymity joked that the tough are those who are hell-bent on receiving an MBBS even though they lack the necessary grades.

Prof Radin Umar says the NOC is only issued to students who will read accredited medical programmes.

And in that advent, there would only be one logical place to go to – an unrecognised medical school abroad.

This process normally involves the services of agents who talk parents into parting with hundreds of thousands of ringgit to enrol their child into a shoddy institution – pocketing a fat commission fee in the process.

It must be noted that many parents are often fooled by a ruse, and this was the case for one Ukrainian graduate.

“The agent told me that the university would be recognised ‘soon’, but I’ve graduated and it still hasn’t happened,” he said.

Hitting out at the unscrupulous practice, Higher Education Minister Datuk Seri Mohamed Khaled Nordin urged potential medical students to tread with caution whenever agents come into the picture.

“The ministry does not appoint or recognise agents,” he told The Star. “We have no link with them and we are not responsible for their activities in sending low quality students overseas.

Dr Jeyaindran says in some hospitals, there are more housemen than patients.

“Continuous reminders to the public are given through the ministry’s website.”

Back to the shady world of wheeling and dealing, agents are often identified by their insistence that students would not need to obtain a non-objection certificate (NOC) – a certificate issued by the ministry to qualified students – in order to study at various medical schools overseas.

In the past, such advertisements were even seen in papers, and agents made a killing by preying on unsuspecting – and often the uninformed – parents.

Shedding light on the topic, Higher Education director-general Prof Datuk Dr Radin Umar Radin Sohadi said that the NOC, in effect for the past eight years, was a mechanism to prevent parents from getting cheated by agents.

“The NOC is only issued to students who will read accredited medical programmes overseas.

“Additionally, it is a mechansim for sponsors to award scholarships or loans. In most countries, the NOC is also needed for visa renewal,” he said.

Review of criteria

Although greater understanding of the NOC’s significance has helped matters over the years, a recent case involving Mansoura University in Egypt showed that agents are still very much in business.

A taskforce that was sent to the university discovered that a sizeable number of Malaysian students did not possess the NOC.

A houseman would normally look after four patients now, down from 10 five years ago, raising concern that interns have fewer opportunities to carry out adequate procedures.

The findings were alarming and the Higher Education Ministry was particularly concerned as Mansoura – fully accredited by the MMC – receives government-sponsored students from the Public Services Department (JPA) and Mara.

It was later disclosed that the students had enrolled with the help of agents, and concerns were raised as agents now had accredited universities in their clientele.

Commenting on the case, a source in the MMC said the agents were pushing their luck by hoping the Government would not reject the graduates as the universities are accredited.

There are currently 926 Malaysian students in Mansoura. The varsity’s homegrown medicine programme has 493 students while the remainder are reading a twinning programme involving the University of Manchester.

Mohamed Khaled said that a joint working group between Malaysia and Egypt had already been set up to discuss and review the criteria of students that would be sent to Egypt for medical programmes in the future.

Under the new ruling, only qualified students – those who possess the minimum academic results and NOCs – will be considered for medical programmes in Egypt.

The ministry’s swift action appears to have effectively countered the movements of agents in Egypt and the establishment of similar committees with other nations might just nip the problem in the bud.

But as they say, change is the only constant and one wonders whether it is a case of check or checkmate for the agents.

The home front

Although foreign universities took most of the brunt, local higher education institutions did not escape unscathed.

A private provider was alleged to have lowered entry requirements in order to fill its initial student intakes, and others were alleged to lack experienced teachers and adequate facilities.

Other concerns include the increasing number of medical programmes offered by private providers, with some offering up to two intakes a year instead of the usual one.

In his blog, Malaysian Medical Association president Dr David Quek said that private providers prioritise public demand over the capacity of delivery in terms of teaching staff and appropriate standards.

Dr Quek said that the increasing number of private institutions had resulted in a shortage of experienced senior clinical staff, and junior specialists who lack experience are hired to teach students.

He added that non-clinical teachers, who cannot be registered as doctors in Malaysia, were imported from neighbouring nations to fill the quota of teaching staff.

As for students, Dr Quek said that many were left on their own to muddle along.

A senior consultant who declined to be named also said that the establishment of private medical schools – at an average rate of one or two a year – over the last decade had lowered the entry requirement of students since these schools required numbers to be profitable.

Others experessed concern that the promotion of Malaysia as a medical hub would add further strain on public hospitals as talent was expected to move to the private sector.

Concerned senior doctors are urging the Government to intervene before it is too late.

Many advocate amending the Medical Act 1971 to make the Medical Qualifying Examination compulsory for all students, as students from recognised schools could also fall short of expected standards.

The removal of the list of recognised basic medical degrees - in the second schedule of the Act - was also proposed.

However, the doctors are divided when it comes to implementation.

Some propose that only graduates from foreign schools should be affected as the entire procedure would be easier to monitor.

However, a consultant said that the standard of final exams in local universities varied widely, and some varsities attempt to pass as many students as possible to look good on paper.

Currently, the exam is only administered to students from unrecognised foreign medical schools.

A senior doctor said the idea of the amendment has been discussed with the Health Ministry, but a solution had not been implemented because local universities wanted to be exempted and prestigious universities in Britain and Australia would likely object as well.

A medical lecturer who declined to be named said that the criteria of the qualifying examination should be made known in advance so that students know what was required of them.

Highlighting the case of a top student from a Ukrainian university who failed the exam, the lecturer said that the different methods of training was an obstacle too big for some.

“No matter how diligent and conscientious students are, the chances of them passing the exam seems next to impossible,” he said.

He said that different examination formats, a student’s unfamiliarity with local practices and the lack of training in medical school were possible causes of their failure.

Concerted efforts

The Government has taken note of the grouses and Mohamed Khaled confirmed that a five-year moratorium on medical programmes in Malaysia was being prepared by the Higher Education and Health Ministries.

“The moratorium is in the final stage of preparation and it will reduce or stop higher education institutions from offering new programmes as the current capacity will be able to meet national targets,” said Mohamed Khaled.

The move is similar to the Higher Education Ministry’s freeze on the number of nursing colleges in the country.

And the moratorium isn’t the only catalyst for change.

The debate on the quality of housemen has made it to the Dewan Rakyat and Health Minister Datuk Seri Liow Tiong Lai said last Monday that six hospitals — in Kuala Krai and Tanah Merah, Kelantan; Segamat, Johor; Lahad Datu, Sabah, Bintulu and Sarikei, Sarawak — would be upgraded to specialist hospitals which train housemen.

With the new avenues, house officers could be deployed in a more efficient manner. Liow said measures had already been taken to ensure quality.

The minister said that the ideal specialist to houseman ratio was 1:5 and each houseman should take care of 14 hospital beds, depending on discipline.

Liow also said that his ministry would be getting 58 contract specialists from Egypt, India and Pakistan next month to supervise housemen.

Liow added that his ministry would look into the possibility of amending the Medical Act 1971 to make the Medical Qualifying Examination compulsory for all medical students.

That said, the relevant ministries have responded with strong statements of intent in the past week and the challenge now is for the Government to strike the right balance.

A balance which ensures that the pursuit of national goals – achieving a doctor to patient ratio of 1:400 by 2020 and the rise of Malaysia as a medical hub – does not compromise the quality of healthcare service in any way.

The road ahead will be tough and if the number of grouses pertaining to the houseman glut are anything to go by, the balancing act will be a fine one indeed.

Source: http://thestar.com.my/education/story.asp?file=/2010/12/12/education/7602864&sec=education

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• Arthritis Writing Excellence Award (General Press award) 2003

Article: Pain in the Knee - Second place – European Medical Writers Association writing course up to a value of $750 (Malta), plus one-year EMWA membership fee

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• Consolation prize for Best Article on Organ Donation 1999

HONOURED....(FROM LEFT) BEST JOURNALIST LEE YUK PENG, THE STAR CHIEF NEWS EDITOR CHUA YEW KAY, HEALTH MINISTER DATUK CHUA JUI MENG, SECTION 2 REPORTER LOH FOON FONG AND ORGAN DONATION PUBLIC EDUCATION COMMITTEE CHAIRMAN DATUK LEE LAM THYE.

 

 

The Star, 14 Oct 2000

Nation, pg 9

Daily awarded for creating awareness on organ donation

PETALING JAYA: The Star swept top honours at the Health Ministry organ donation media awards here last night.

The English daily was judged the best newspaper for creating awareness on the topic of organ transplant among its readers.

Chief News Editor Chua Yew Kay received the award on behalf of the newspaper from Health Minister Datuk Chua Jui Meng.

News reporters Lee Yuk Peng was also voted the best journalist by the panel of judges for her series of articles on organ transplant. For her efforts, she was rewarded with a RM2,000 prize money, a trophy and a certificate.

Section 2 reporter Loh Foon Fong also won a consolation prize for her feature article on organ transplant.

The category was won by China Press's Kaw Pai Yeow, who received a RM750 prize money, a trophy and a certificate.

Earlier, in his speech, Chua said exposure from the media on the subject had managed to increase the number of organ pledges in the country.

"From 1998 until September this year, the number of pledges have risen from 2,300 people to close to 26,000 people.

"From this number, 71.5% are Chinese, 21.1% Indians and 3.3% Malays," he said.

He also advised the media to be sensitive in their reports on organ tranplant and to remain guarded over the donors' and families' wishes for confidentiality and privacy.

"This is because organ donation is still a very sensitive issue. The media must play its role by highlighting positive, creative stories on organ donation," he said.

Religion, Society and Public Policy Study 2006

An exchange trip organised by The Asia Foundation
Funded by the Freeman Foundation 
April 21 to May 7, 2006

Report by LOH FOON FONG, Malaysia.
(The ASEAN participants flew to the United States for the study trip while the Americans left for ASEAN countries during the same period.)

The Malaysian participants from left: Umran, the human rights activist, Shan, the lawyer, Khal, the academic and Foon Fong, the journalist.

New York: Separation of state and religion 
The First Amendment to the United States Federal Constitution requires that the Congress makes no law respecting an establishment of religion, or prohibiting the free exercise of religion.

On the first day of the programme proper, Morris L. Davis, Asst Professor on History of Christianity at the Drew University in New Jersey explains over lunch at the Bronxville Episcopal Church that the separation of state and religion was introduced by the early founding fathers who wanted to turn away from the oppressive established church experience in Europe.

Davis points out that allowing the church to be the state’s established church would create a situation where no one is going to agree on which denomination or whose religion gets to the win the seat, and the struggle can lead to war and persecution. Besides the church’s pastor Daniel Gunn, other members of the Episcopal church members, United Nation’s Ombudsman James Lee and Judge Colleen McMahon were present during a dialogue on religion in America.

 The boundaries of religion in the public sphere is continuously being challenged and debated. Dr Ann Pellegrini, associate professor on Religious Studies and Performance Studies at the New York University says that many of the court cases on religion have been interpreted through the Protestant's perspective.

For instance, polygamy was banned in 1878 and the Mormons, who practise polygamous marriages, had to adhere to the law, however, when the Amish community sued the government for imposing their families to send their children to school until age 16, the former won the case. The Amish families had wanted their children to come out of school after Grade 8 for they have a long tradition of religious practice on working in the farm.

The other issue that is still being questioned, says Pellegrini, is: “What does democracy mean? Does it mean that the majority rules or that it has space for everyone, including the minority groups?”

She says among other issues that could link to religious beliefs and are constantly being debated include evolution versus intelligent design in school education, sex education and health policy.

R. Gustav Niebuhr, associate professor in Religion and the Media from the Syracuse University points out an interesting facet of America’s religious life. Quoting from the Gallup Poll, he says 95% of Americans believe in God or a higher being and this is unlike Europe, Australia and Canada where most people do not believe in God anymore. He says from the studies, 80% of America said that their belief in God was very important and 40% attend religious gatherings.

Gallup started asking these questions in 1939 and the statistics today have not changed much, says Niebuhr. The paradox is that since religion is voluntary compared to Europe, people seem to be more fervent and sincere in their faith, hence the vibrant religious life of the Americans. In the US, 50% of Americans are Protestants while another 25% are Roman Catholics. The Jews, Mormons, Hindus, Buddhists and atheists make up the other 25%.

Niebuhr says that in 1620, when the Protestants landed in Massachusetts, there was a creation of legally uniformed governing believers. There were no one dominant group from the eastern sea band that landed in New York, New Jersey, Pennsylvania and Maryland. There were different denominations of Protestants as well as Roman Catholics.

James Madison 1784-86 engaged in a landmark debate in Virginia about whether tax payers’ money should be used to hire and pay teachers to teach Christianity. Madison said religion is beyond the law and difficult to legislate. Moreover, he pointed out that the Congress cannot establish a religion. However, the state did not disassociate itself from religion until later.

In 1791 when the US achieved independence, there were not many churches then but there was a Revival from 1800-1860. In various period of history, there were people who were very adept at keeping the religious vitality. For instance, there was Chas Finney, an attorney who persuaded and preached daily from his office, Billy Sunday, a baseball player who used the language of baseball to win the people to Christianity and in the last century Billy Graham, an evangelist.

From Niebuhr's perspective, people used religion to change society. Slavery, child labour, women’s rights and alcohol abuse have been fought through the Protestant’s moral conviction. Rauschenbusch introduced the “social gospel.” He believed that the gospel should not change only individuals but society. This has an enormous impact on Martin Luther King, Jr. whose father promoted social gospel. King led the African Americans in the civil rights movement from 1955-65.

The struggle for respect and the place of religion in the public place is the most important issue in the US’ religious life, says Niebuhr. In 1962, they banned prayer in school.

“When a mayor introduces a certain religion or establishes a certain religious practice, that is constantly being worked out in the Courts,” he says.

On the discussion of the controversy over the Danish cartoons, he says all the editors in the US decided not to use the cartoons except for one. While the Europeans defended their stand based on freedom of expressions, Niebuhr feels the question should be: “Does having the right to do something should mean one should do it?”


Interfaith initiatives
The meeting with Rabbi Laurence A. Sebert from the Town and Village Sygnagogue was a fascinating experience. He told us about Judaism, read/sang to us the Torah in Hebrew.

Rabbi Sebert showing us the Torah in the Town and Village Sygnagogue in New York.

What was most encouraging was, when asked if there was any point in time that the conflict between the Jews and the Muslims in Middle East has any carried-over effect for them in the US, he said, “No.” In fact, after the Sept 11 bombing occurred, he went to the Imam of the mosque near him, and the Christians, and they got together to mourn and pray, each in their own ways. They also had dialogues to forge better understanding of each other.

At the Russ & Daughters Appetizers kosher food store in New York.

Another interfaith initiative was the “Seeds of Peace” – where Jewish, Muslim and Christian youths go to camp together. 

The Interfaith Centre in New York experimented with several approaches to interfaith initiatives. The liberals are liberal in theology and politically and started to invite the Conservatives but they are not interested because they do not find the need to learn about other religions, says Raffaele Timarchi, Program Manager of the Interfaith Center of New York. However, when they began to focus on social work, the different religious groups were more willing to work together.

Side note: A discussion was also held with Asian American staff workers who briefed us on the bad working conditions of immigrant workers especially the undocumented ones. The churches were helping out with their needs.


Atlanta: African American civil rights movement
The tour to the Martin Luther King’s Center in Atlanta revealed King’s vision and peaceful methods of protest.

At the Ebenezer Baptist Church where Martin Luther King Jr used to preach.

Dr Drew Smith, director of the Public Influences of African-American Churches Project at Morehouse College in Atlanta, explains to us the role of the African American churches in leading the civil rights movement.

The civil rights movement started in the 1900s and peak in the 1950s, he says. Most protests took place in the south eastern part of the US, especially Montgomery, where King held peaceful demonstrations.

The best progress seems to be not insisting on the rights of the African Americans but to start with meeting their social and educational needs. It is basically to start where one is and not to dream too far off goals, says Drew.

Interestingly, the support from the churches for the civil rights movement were only 10% while most were more interested in evangelising rather than be involved in social activism.
Nevertheless, those involved were a main force in the struggle (there were other social organisations involved too), says Drew.

Before 1960s, policy that rolled out addressed discrimination that had existed for centuries. The number of lobbyists in the 1960s increased tremendously and by mid-70s, the US saw social lobbying moving to the governmental level.

The struggle of the African-Americans led to new claims of demands from other Asian ethnic groups. The Latino community (14%) which is larger than the African Americans (13%) have not been able to function like the African-Americans who have officials in at the governmental level, hence, they go to the streets.

Health and social welfare issues are still the main policy concern for African Americans. The African American women draw a distinction between them and the white American women and call themselves Womanists and not Feminists because they perceive that in the latter, the males were demonised.

African American Muslims
The visit to the Atlanta Masjid of Al Islam in Atlanta was another highlight. The believers shift through Islam and were careful in not adopting the cultural elements from other countries and this requires a lot of critical thinking, says Imam Plemon El-Amin, a native of Atlanta and Harvard graduate who converted to Islam in 1974 at age 24.

Lunch at the Atlanta Masjid of Al Islam

  
The challenges faced, he says, are the ignorance about Islam. Most of the time, Islam is portrayed through the lense of the Middle East. He says that America is the best place to practice Islam because of the freedom of religion provided for by law.

It is interesting to note that the Imam akin the issue of apostasy to the laws on traitors - the apostasy referred to in the Quran was those who turn in the midst of battle and hypocritically went to the other side to defeat the Muslims.

For the ordinary people who want to come out of Islam, he says, they are free to do that because the Quran says that there is no compulsion in religion. This interpretation is totally different from many Malaysian Muslims who believe in death punishment for apostasy.

Most of the Muslims in the US are African Americans. When a question was posed on why it was so, Plemon says that when the Africans were taken away as slaves in West Africa, their Islamic religion was also taken from them. The slave masters were white Christians and they see it as the religion of the oppressor. They were forced to convert to Christianity but now they decided to return to their original religion.

Asked about their view on setting up an Islamic state, Yusef Burke, Council on American Islamic Relations in Atlanta says it is not possible to set up an Islamic nation. “It was a beautiful system but I don’t believe that it will exist again. It is impossible in a pluralistic society. It may work in a small country.”


Iowa: Federal funding for religious groups
The meeting on federal funding for faith based social service programme at the Governor’s office revealed that those with religious background volunteered the most in social work and gave the most money to charity.

While religious bodies are not taxed, the US does not provide financial support to religious organisations for spreading their religious faith. The non-faith organisation have to file tax information but religious organisations, such as the churches, do not have to.

If mega churches supply social services to everyone, and are more concerned with helping people rather than converting them, they can get government funds, says Stanley (full name not available). This support was introduced by President Bill Clinton.

Richard (full name not available) says for substance abuse, faith-based treatment has been the most successful. There is also high demand for faith-based prison rehabilitation programme. However, the challenge is: should those who have committed severe crimes be given opportunity to be rehabilitated in communities and for sex offenders, should they give notices to their neighbours about their offences?

On the issue of funds, most volunteer work are considered “private” but since money is contributed by members of the public, hence, NGOs have to be transparent, he says.

The problem in the US is if money is not given to faith based organisations, very few groups would give social services. Actually, receivers of funds are also skeptical about receiving government funding because of a possible government control.

The session with Iowa Commission on Volunteer Service on how the state-wide vision for national and community service initiatives are integrated into state-wide program and debate surrounding the notion of using public funds to support religious organisations were not presented.

Hispanic outreach
Kirk Martin, coordinator of the Hispanic Community Outreach Program from the Catholic Charities Diocese of Des Moines says the churches are speaking up for the immigrants. As many Iowa people are ageing and the young moving out, immigrants are moving in. Around 60-70% of Hispanics are from Mexico, while others are from Latin America.

For undocumented workers, people get injured and are not compensated and they cannot complain because they do not have documents. Many undocumented workers came because of their families. The church feels that using military force to keep people out is not a humane way.

Children of immigrants can enrol in schools but not eligible for food stamps and medical emergencies.

Side note: On an overnight homestay programme over a weekend, participants are linked up to hosts with faiths similar to theirs for participatory purposes or they could choose just homestay and interact with hosts in relation to the topic of this study trip. I homestayed with Denise and attended a church service at the Lutheran Hope. She considers herself a conservative Christian but says she does not support Bush’s foreign policies, contrary to media stereotype reports. She says the Christians in the US are very diverse in their thinking and could not be categorised rigidly as often portrayed by the media.

Awww... just when I thought I managed to capture a perfect pix of us.... On the way to Kalona City, Iowa, with the ASEAN participants.

When meeting a representative from the Amana community (they are a bit similar to the Amish community), the writer had asked why the communal living and allocation of jobs and resources could work in their community while the communist system had failed, the rep said it was due to their faith in God. (The Amish and Amana communities are a rare group of Christians in the United States who have  shunned modernisation, unless they are necessary.)

The visit to a Japanese Buddhist church showed how immigrants assimilated by adopting some Christian exterior practices such as calling their priest “Reverend,” and building a temple like a church with church pews but with idols in the front of the temple.


San Francisco: Conclusion

The American and ASEAN participants converging in The Asia Foundation office in San Francisco.

 Some of the points discussed relevant to the Asian group were:

•    Separation of state and religion seems to be a model that works well for a pluralistic society. There is also space for people to hold discussions to resolve issues without turning to violence. 

•    The debate on pluralism and interfaith efforts – does it mean coming together to learn of each other’s religion or coming together to address social structures and problems?

•    The philanthropy in America is unique and should be emulate. Why do people set up foundations? Based on religious conviction and to get tax exemptions.

•    The meaning of democracy should also be explored – is it determination of choices by the majority or that everyone, including the minorities also have a say?

The exchange trip was a fruitful one and it certainly enabled the Americans and the South East Asians see how pluralistic society operates in the two regions. The US experience showed how a pluralistic community could live together in peace and harmony while they have their rights protected.

The Golden Gate in San Francisco.

End of trip - at Julia's house in SF.