Engaging Grassroots Perspectives on Health and Well Being in Northeast Thailand and Lao PDR

In the UK cholangiocarcinoma - known as CCA, or bile duct cancer - is classified as a rare cancer, affecting only around 2000 or so people each year. In parts of mainland Southeast Asia, however, and especially in Northeast Thailand (Isan) and Lao PDR, it is among the most common cancers to be diagnosed. Doctors treating the disease at Khon Kaen hospital in Isan witness a regional burden in excess of 20,000 cases per year, while estimates of those suffering from the disease in Lao PDR are even higher. The prevalence of CCA in mainland Southeast Asia is predominantly caused by widespread infection with liver fluke that results from the deeply culturally embedded practice across this relatively impoverished region of consuming raw and partially cooked freshwater (cyprinid) fish as a ready source of cheap and sustainable protein. To date public health campaigns in Thailand have been largely characterised by a top-down approach, in keeping with a more widespread, hierarchical social structure that tends to place rural citizens as socially inferior. This is reflected in interpersonal relations where open self-expression and agency among grassroots communities in formal contexts, such as engagement with local authorities, education and health officials has tended to be impeded. Furthermore, the relationship that pertains between the Thai state, centred in Bangkok, and the peripheral, rural hinterland of Isan and neighbouring Laos is one of inequality, with the former deeming the latter to be culturally and civilisationally inferior. As a result, for over the past 50 years public health campaigns against the consumption of raw and fermented fish have had limited effect. This proposal therefore aims to explore innovative and effective ways in which the voices of those deemed at risk of developing CCA can be expressed and listened to and carefully heard on their own terms. Its intended outcome is to find meaningful ways in which local communities in Isan and Lao PDR can contribute to and direct their own public health interventions in ways that are most meaningful to their everyday realities and health priorities. We therefore propose to engage with those at risk of CCA in innovative and creative ways to develop broader, contextual understandings of health in relation to a range of related issues driven by the communities in the affected areas. Through a series of community-focussed workshops led by local filmmakers, artists, writers and poets and mediated by local NGOs and academics, this project invites grassroots expression of important daily concerns on the following themes: perceptions and interpretations of well being; life priorities and approaches to risk; diet and nutrition; definitions and significance of cultural and regional identity; and experience and understandings of the physical body in relation to both mundane and spiritual practice. The resulting artworks produced in the workshops - short films, drawings, paintings and pieces of creative writing and reportage - will form the basis of an exhibition that will tour the schools and hospitals of the region as well as having a more interactive presence on social media (Facebook and Line). Taken together, the workshops and exhibition aim to trigger a wider appreciation of bottom-up perspectives on the specific healthcare issues facing the region as well as the more general context of health and wellbeing in which those issues appear. The potential benefits will be in feeding this important, yet formerly little heard and acknowledged grassroots voice, into more effective public health campaigning and policy making in Thailand and Lao PDR with reference to CCA and other healthcare concerns (such as diet related diabetes, hypertension and heart disease).

The project has a wide range of potential beneficiaries:
1. The primary beneficiaries of this project must be the local communities in Isan and Lao PDR, members of whom will, through participation in the workshops, develop innovative and creative ways of expressing their ideas in relation to wider questions of health and well being and with particular reference to the following topics: perceptions and interpretations of well being; life priorities and approaches to risk; diet and nutrition; definitions and significance of cultural and regional identity; and experience and understandings of the physical body in relation to both mundane and spiritual practice. The aim is that this will help them to achieve greater degrees of agency in recognising their own health and well being concerns and to negotiate those concerns more confidently with other healthcare sector workers. A related benefit will be that through creating and exhibiting their artworks they develop a greater sense of confidence in having their voices heard and respected in wider society.
2. The secondary beneficiaries will be those engaged in the care and treatment of patients in the healthcare sector in Thailand and Lao PDR as well as those working in the field of public health campaigning and healthcare policy. The input of material from the grassroots perspectives will aid the development of more nuanced approaches to healthcare and educational campaigns, not only in connection with CCA, liver fluke infection and the consumption of raw and fermented foods, but with disease and ill health in the wider sense of those terms.
3. NGOs working with local communities will benefit from the innovative approach to engagement through the creative arts, allowing them to experiment with and develop new tools for encouraging grassroots self expression. The workshops will help with their networking activities with local artists, writers and filmmakers committed to further public engagement.
4. It is anticipated that artists, writers and filmmakers will themselves learn from the experience of working with grassroots communities and NGOs (and even academics) that may inspire further community-based interventions.
5. Since much of the public health campaigning against OV and CCA in Isan by organisations such as CASCAP is directed at the younger generation, the impact of the touring exhibition on educational initiatives in schools will feed into teachers' approaches to health education and the way in which schoolchildren receive and understand these message. The younger generation will also be key beneficiaries of the creative workshops where they are active participants.
6. Organisations such as CASCAP and the Cholangiocarcinoma Foundation of Thailand, who will inherit the touring exhibition will also be a beneficiary of the scheme as it should help them to broaden and make more effective their approach to health eduction re OV and CCA.
7. Academics working on CCA, issues of public health and of community-based research more widely will benefit from the findings of the project with regard to exploring similar ventures. However, it is not the intention of this FoF project that the main beneficiaries will be in the field of academia.
8. The implications of this project mean that further benefits may be felt by healthcare workers, patients, and NGOs not simply in Thailand and Lao PDR but in other parts of the world. We seek to explore these implications with the project partner charity AMMF in order to take the initiative forward in the future in the UK.