背景

  NPO法人ジャパンハートは2018年カンボジアにこども医療センターを開設し小児がんの診療に取り組んでいる。カンボジアの多くの公立病院では栄養管理された給食提供はなく、患者の食事は家族が準備する必要がある。一般的に患者家族は衛生や栄養に関する知識が乏しい中、食事を病院周辺の屋台で購入し患者に与えており、治療に必要十分な栄養摂取は難しい。当院においても、小児がん患者の治療にあたり同様の課題があった。さらに、カンボジアに栄養士制度はなく医療者でさえ栄養を学ぶ機会が少なく、栄養に関する知識が乏しい。特に、患者に対し効果的な治療のために衛生的で栄養のある食事が不可欠と考えた。そこで、患者が入院中および退院後も衛生的で栄養のある食事摂取ができることを目的とし2019年「ジャパンハートこども医療センター給食プロジェクト」を開始した。栄養士資格を持たない現地人調理スタッフを育成し給食を通じた小児がん患者の栄養改善に取り組んでいる。本活動報告の目的は栄養士資格を持たないカンボジア人スタッフによる病院給食提供や栄養教育の効果を測定すること、これらによる小児がん患者の栄養状態の変化を明らかにすることである。

方法

  小児がん患者を給食提供と栄養状態アセスメントの、付き添い家族を栄養教育の対象とした。日本人栄養士・調理師が勉強会や衛生マニュアル作成、最低食事多様性水準（MDD）を参考とした献立基準作成などを行い、現地人調理スタッフが給食提供や衛生・栄養教育をできるよう育成した。衛生的で栄養バランスの良い給食を提供するために、マニュアルに基づく衛生管理や献立基準に基づいた献立作成、喫食率測定などを行った。また、患者家族に対し衛生・栄養教育を行い、知識や意識の改善を図り教育の前後で調査を行った。さらに、身長体重測定を行い、WHO Growth Chart BMI for ageにより栄養状態評価を行った。

結果

  献立のMDD達成率は72％から100％（開始後1週目−2週目（2021年1月））に増加し、月平均喫食率は45.9% から最大80.5％に増加した（2020年4月～2022年1月）。衛生・栄養教育実施前後の調査では89.1％の患者家族に知識や意識の改善が見られた。身長体重をBody Mass Index（BMI）で評価し、BMI for age≤−2SDの割合が入院時28.1%から退院時（最終測定時）15.9%に減少した。

結論

  日本人栄養士・調理師の関与により、現地人調理スタッフが衛生や栄養に配慮した給食を提供することを通じ、患者の栄養状態の改善に寄与することができた。栄養士制度のないカンボジアで栄養改善活動を持続するためには、栄養を専門としない現地人が実現可能な活動内容で取り組むことが重要である。さらに栄養面からの治療をサポートしていくために、カンボジア国内における栄養人材の育成が望まれる。

  In the increasingly globalized world, developing global health competency (GHC) education by determining the required core elements for undergraduates is on the rise. A growing number of people from different backgrounds have migrated to Japan. To accommodate their various healthcare needs, potential GHC elements that facilitate Japanese GHC education should be identified. This paper aims to extract some of the key GHC elements required for students in medical and healthcare fields based on the abundant experience of Japan’s international health cooperation and to make recommendations for GHC education in Japan and worldwide.

  To date, Japan’s international health cooperation has cultivated a variety of competencies to realize its mission of reducing global health disparities. Japanese GHC elements are the bases of core concepts in healthcare and share commonalities with GHC elements in global communities: Cultural competency, “Go to the People”, respect for diversity, transdisciplinary collaboration, capacity building, independence, people/patient-centered healthcare, and empowerment.

  Comprehensive preparation of these elements is found among kabuki kurokos (black robes), people dressed in all black who assist kabuki actors onstage during performances. The black worn by the kurokos means “nothingness”; they should be invisible on stage, so as not to interfere with the performance. Kurokos understand the culture (values, behaviors, etc.) of the lead actors, manage and coordinate stage proceedings to meet the actors’ needs, and help them achieve the best performance by collaborating with other backstage workers.

  Kurokos’s empowering leadership competency is akin to the Western concept of servant-leadership, which emphasizes being a servant first and devoting oneself to enabling greater health and independence/autonomy among vulnerable people. Japanese educators can exemplify kuroko values by providing their students with GHC education. Japanese GHC elements can be integrated into worldwide GHC education. Spiritual care is also essential for inclusion in GHC education to develop students’ holistic care competency.

  An online lifestyle has become typical with the COVID-19 pandemic. Although the number of infected patients in Japan has decreased significantly from its peak, concern remains about the seasonality of the infection and the possibility of variant strains. In this context, 10 medical students and Dr. Shigeru Omi, Chairman of the Subcommittee on Countermeasures against Novel Coronavirus Infections, held an online panel discussion on November 6, 2021.

  First, the frailty of Japan’s testing system compared to other countries was highlighted. Although weekly testing for all citizens would be ideal, implementing efficient countermeasures with limited resources was emphasized.

  Second, concern exists about other diseases because people are refraining from receiving necessary medical examinations for fear of being infected with COVID-19. Strengthening mass approaches using the media and personal approaches by health care professionals is essential.

  Third, much false information exists on social networking sites and is being spread. The importance of suitable individual risk communication was suggested.

  Finally, medical students mentioned the loss of experience due to restrictions on school attendance and club activities. Although medical students are treated differently in each country, increasing opportunities to discuss the purpose of medical education and whether online alternatives are possible were highlighted.

  This was the first opportunity for a direct discussion between medical students, who have been greatly affected by COVID-19, and Dr. Omi, a policymaker. We hope that more such discussions will be possible, and that people’s opinions will be considered toward a better environment.