Academe and public health

Life in the academe at first glance can be just like any other job; like in all other careers, one gets involved in a rat race with the aim to climb up the career ladder, to gain both reputation and higher remuneration. Not to mention the privilege to brandish one’s fancy academic attire year after year during commencement.

This was my first impression of the academe, when I chose it as an alternative career track after finishing a stint in government. I intended to do research to supply evidence that will support health policy in my country. Also part of this motivation was to share my experiences to students and fellow faculty.

I soon realized that this was not just what the academe is all about. Now, almost four years since I chose this career track, I now fathom the immense importance of the academe in pushing further the boundaries of knowledge, and defining what it means to be in public health. Cliche as this may sound, accomplishing such a duty entails finding new approaches and concepts to teach to my students, making sense of current and emerging trends in my field of endeavor, and catalyzing discussion on how to solve the problems of the world today. 

All these sound like mammoth tasks to achieve, but what I find deeply consoling in the academe is that all these starts with the stroke of pen and ink. In an attempt to respond to real world needs, we academics write the ideas brought forth by deep introspection and analysis of the problems set before us. 

Pragmatic thinking may dismiss academic publishing as non-productive; indeed, matters discussed for the sake of discussion with action as mere afterthought are often deridingly deemed moot and “academic.” But my experiences in the field taught me that academic writing serves a uniquely important purpose: it serves to challenge norms and paradigms, allowing us to zoom out of conventional ways of solving problems, and propose suitable solutions. 

In my past work in public service, I aimed to solve public health problems while looking at the context of my clientele: their culture, their socio-economic concerns, and their collective aspirations. I believed that using this approach would result in interventions that are acceptable, affordable and appropriate. 

However, many public health programs were implemented by following checklists and monitoring success indicators that were determined by program managers and policy implementors who were marginally aware of the context of the target population. I couldn’t blame them, as this was the only way to ensure well-monitored progress of health improvement for a budding health system such as ours. 

In this system, these interventions started with a written plan, which usually followed a certain template set by legal and bureaucratic protocols. Though there was room to propose adjustments applicable to the local setting, due to the sheer volume of work, health officers would just stick to accomplishing bare minimums. 

In this system, many an implementor would be wont to say: As long as our scorecard wasn’t red in this indicator, I’m OK. As long as I’m not rock bottom in my province, I’m OK. As long as I don’t have any maternal or neonatal death in my jurisdiction, I’m OK.

Indeed, it’s OK. But does this lead to achieving the “best possible state of health?”

Back in medical school, I was introduced to the concept of working towards the “best possible state of health for all,” a principle upheld by the WHO Alma-Ata Declaration on Primary Health Care in 1978. Despite its battlecry for community-managed health care and “health in the hands of the people,” due to various practical reasons, health care became fragmented, compartmentalized, and indicator-driven, both in government and private sector health management; what, with the emphasis on financial accountability and the need to prioritize interventions that generate the greatest apparent return of investment.

Clinging to my belief in providing the best possible health care for all while being aware of the current practical difficulties in implementing the Alma-Ata Declaration, I felt that approaching health problems from an academic standpoint would enable me to zoom out from this state of affairs, and investigate approaches that would truly produce the best possible health. 

This is why I chose to be in the academe. I still believe in health for all, and I want to be at the forefront of how it is to truly achieve it.

Why I travel

Since childhood, I’ve always dreamt to travel the world.

Now that my career objectives are becoming clearer, I now choose to believe that this passion for travel serves a purpose: it reminds me of how I should be open to new perspectives and experiences. Very useful, especially for someone carving a career in the academe.

In the middle of my mid-year vacation in Taiwan, I met up with a public health researcher from another Southeast Asian country, four years my senior and already a post-doctoral research fellow at Taipei Medical University (TMU). In between more light-hearted topics, I was asked by my new friend about the research I was doing. With cordial but hard-hitting frankness, he told me that my subject matter is already obsolete, and I need to look at new angles to solving public health problems.

I was stunned.

Thankfully, he invited me on short notice to attend an international public health summit, a collaboration between TMU and the schools of public health of the University of Tokyo and the National University of Singapore. I expected that it would be a chance to be updated. I was looking for a new conceptual framework on which I could help improve my thinking patterns as a budding researcher in my field.

Gladly, I wasn’t disappointed. There were three key messages that I picked up from the summit:

  • More than just focusing on the science, public health needs to develop its own art. It should provide solutions that not only address superficial needs but also, “hidden commitments” and cultural norms, which require a more creative approach.
  • Public health should shake itself off from a fragmented, health service-oriented conceptual framework imposed on it by biomedical science. As it is a public discipline, it needs to integrate points of view from implementors, academics and frontline health workers. It needs to be led by people who know how to carry out interventions, promote them and assess them.
  • Finally, public health should provide its practitioners with the skill to zoom out of the picture and recognize one’s role in maintaining health security. This should go beyond political boundaries. As a partially recognized political entity without benefit of full membership in various international organizations, Taiwan is quite experienced with this. In pushing for a greater role in maintaining health security, it used one of its most powerful forces: its academe.

Somehow my experiences have taught me these things, but it is gratifying to hear these lessons straight from the experts.

This gathering reminded me to regularly zoom out and connect with like-minded researchers who have amassed experiences and have become prolific authors. When asked about his secret, my new friend told me that it’s all about being passionate for one’s chosen field of research. If one is indeed passionate, he would be willing to sacrifice time and resources to achieve one’s goal.

I am happy that these realizations became part of an already existing passion for travel. But I’m more happy now I now have a better reason.

It will challenge me to be more productive, as I continue my goal to bring the barrio doctor voice to the academe. It will allow me to become a better public health researcher.

Finally, it will allow me to work better towards the goal of promoting “health for all.”

***

Thanks to Dr. Tuyen Van Duong for inviting me to this event (and for taking the picture above), and for Dr. Don Prisno for linking me up with colleagues at Taipei Medical University.

The speakers at the International Public Health Summit at TMU were Dr. Masamine Jimba, professor of community and global health at the University of Tokyo, Dr. Chia Kee Seng, dean of the Saw See Hock School of Public Health at the National University of Singapore, and Dr. Kuo Nai-wen, dean of the school of public health at TMU.

Getting fit: a health policy perspective

While on the train from Sunday service, I contended with a Facebook-induced self-insecurity. One of my friends had posted an article about a TV personality who lost 65 pounds in 90 days. With a shot of envy running down my spine, I clicked the link, wanting to know how he did it.

It turned out that his fitness journey wasn’t any ordinary resolve to lose weight. It took him two to three hours of daily exercise, with close monitoring from a personal trainer and a nutritionist.

Thinking about my personal fitness journey that I started recently, I thought to myself: how long would it take me to lose that amount of excess weight? As a man standing at 5 feet 10.5 inches, it would greatly benefit me to lose about that amount of weight to attain the ideal weight for my height and age. Feel free to do the math what my ideal weight should be.

But, from a public health perspective, with a rising percentage of Filipinos (and other Southeast Asians) becoming overweight, the promotion of healthy lifestyles is becoming increasingly important in this part of the world.

Interestingly, a tactic that health clubs and gyms usually do to promote their facilities is to point out that hindrances to maintaining a healthy diet and a regular exercise regimen are mere excuses. It actually works well in a country where this maxim is well-followed: “Kung gusto, may paraan; kung ayaw, may dahilan.” A loose translation of this is “If one sets out to do something seriously, he will find a way, despite difficulties. If one refuses to exert the effort, he will always have excuses.”

Most of the time, however, a lot of these excuses are valid.

For instance, middle-aged workers and professionals would usually be unable to keep to a regular exercise regimen because of long commutes to and from one’s workplace, the need to take care of one’s family, or the need to periodically accept overtime work or side jobs to augment one’s meagre income.

Another perspective is food choices, where usually, low-fat, organic or other healthy lifestyle-friendly options are more costly than ordinary, fat-rich variants.

Yet another concern would be the difficulty in using sidewalks and roads for jogging or running, due to their poor condition, or the risk of being mugged.

It is unfortunate that regular folks like you and me are faced with these obstacles that, if surmounted, would enable more people to pursue healthier lifestyles. Though individually, people may choose to adopt healthy lifestyles, these efforts would be largely influenced by how well they earn, and how much time they have in their hands. Using public health-speak, as with any other public health concern, healthy lifestyle promotion is also heavily influenced by social determinants of health: the social, cultural, economic and political context in which people live and work.

I believe that healthy lifestyle promotion is a moral obligation for ministries of health, and that this needs to be closely tied with workplaces, which may assign specific days for physical activities, or put up facilities where employees can engage in physical activities.

Equally important is the need to coordinate efforts with public works and law enforcement, in order to design and monitor roads, thoroughfares and public spaces with healthy lifestyle promotion in mind; that these spaces be walkable and safe, and that people can run on them and organize group exercise activities with them.

Maybe soon, with all the social determinants impeding healthy lifestyle promotion addressed, we may all be able to attain our respective ideal weights, or even the figure we like, without the need to spend all the money that that TV personality might have spent, just to lose 65 pounds in 90 days.

In conclusion, despite current difficulties, healthy lifestyle is still an individual choice. But in the interest of public health, if we want more people living longer, healthier lives, governments and health agencies should not just promote a healthier lifestyle, but facilitate it as well.

Read more:

Friel S, Hatterly L, Ford L. (2015). Evidence review: addressing the social determinants of inequities in healthy eating. Carlton South, Victoria, Australia: VicHealth. Retrieved from: https://goo.gl/wNioC7

Villaverde M, Vergeire R, De Los Santos M. (2012). Health promotion and non-communicable diseases in the Philippines. Quezon City, Philippines: Ateneo de Manila University. Retrieved from: https://goo.gl/07SyGo

 

Class attendance and mutual respect

A rising concern in medical schools is the growing phenomenon of people not showing up in class.

It’s quite understandable. We are in an age of instant gratification–people nowadays want instant results, or else they look for better ways to achieve the results they want. This way of thinking has seeped into various aspects of daily life: the way we eat, the way we work, and yes, even the way we study and learn things in school.

Relating to the latter, students in post-graduate settings like medical school have developed a sense of which activity is high-yield and which isn’t, thus leading them to decide against attending an activity that has been pre-judged as low-yield. In addition, an MIT study noted that the two strongest factors that lead to a decision to skip class included the poor quality of lectures, and deadlines for other academic work.

Meanwhile, medical school professors, who are usually busy for various reasons–clinical practice, research, and other academic pursuits–end up feeling disappointed and enraged for not gaining the satisfaction of being listened to by students, who will most probably be their future colleagues. The poor attendance in these lectures have resulted in what I perceive as disrespect of seniors, which is quite a serious infraction in a hierarchical field like medicine.

I am no stranger to this phenomenon. In my biostatistics class a few weeks ago, for instance, there I was, eager to teach students about hypothesis testing. Out of around 60 medical students, only less than 20 showed up. Already frustrated but also appreciative of those who made it to class, I tried my best to sustain the enthusiasm and teach the lesson anyway. Upon investigating the reason for the poor class attendance, I was told: “Doc, everyone else is busy cramming for the test coming after your lecture.”

Expectedly, when the topics I lectured that day came out in the long exam for that subject, most of the class failed miserably. For the students, the pain of failure may have been felt only once: at that one time they flunked my examination. But for professors, such a poor performance is an added insult to a pre-existing disappointment. It leads the professor to reflect and ask oneself: “Did I do anything wrong?”

Preparing for a lecture takes hours, even days, and a lecturer can only hope that the effort wouldn’t be in vain–that is, that there are actually students who would be able to listen to the lecture, and master the concepts well enough to excel in examinations and put the knowledge into meaningful practice.

But perhaps, taking the students’ perspective, these lectures may need to morph into more intellectually stimulating activities that turn “students into active participants rather than passive listeners,” as this study published in Science suggests.

Nonetheless, I also think that even if we train all medical school professors to adopt the aforementioned paradigm and design more stimulating learning activities (which obviously appeals to a generation accustomed to instant gratification), we can only do so much. There will always be topics that would be more appropriately taught through lectures.

A more important point though is the fact that medical school, in my humble opinion, is a different setting altogether. It must be pointed out that the studies cited previously were carried out in undergraduate degree settings, where learning is usually an individual affair, and one chooses to undertake courses to accumulate adequate knowledge to get employed.

On the other hand, I firmly believe that the practice of medicine is not mere employment. It is a lifetime of service.

As such, I believe that medical school cannot be likened to a knowledge vending machine where one selects courses to attend. Attending medical school for me is choosing to immerse oneself in a culture of lifelong learning to which one must wholeheartedly adhere for a lifetime. This way of life is pervaded by this one single virtue: mutual respect. This virtue reinforces the central dictum that governs the practice of medicine: to do no harm. It is the sense of engaging with one’s client, colleague or co-worker in a way that is consistent with the human dignity we all share. To put it in religious terms, it is giving what is due to another person, who like all other human beings is an image and likeness of God, to love one’s neighbor as one loves the self.

Following this reasoning, it behooves medical students to listen to their professors and attend their classes, for it is a matter of respect. On the other hand, mutual respect, to be fair, does not only admonish students to attend class. It also requires teachers to be sensitive to the needs of students, and adjust strategies accordingly.

Admittedly, the issue of class attendance is influenced by a myriad of factors. Notwithstanding, mutual respect requires that these factors be discussed through compassionate dialogue, that eliminates double standards in dealings between faculty and students, lays out all issues, and resolves them with firmness, finality, and political will. In my humble opinion, compassionate dialogue would be able to address issues such as the quality of lectures, or overlapping schedules for exams and deadlines for school work, which have been shown as influencing factors in class attendance.

I also believe that medical schools deeply rooted in the virtue of mutual respect are bound to produce doctors with unimpeachable character and genuine compassion for patients, colleagues and other health staff. I believe that students who give due respect to the efforts of their professors are those who would think twice before leaving duty posts without permission and engaging in unethical acts inimical to the sacredness of the medical profession. I likewise believe that students who are raised in this virtue are those who are consistently motivated to perform their best in hospital and clinic duties.

Conversely, I believe that professors who practice mutual respect are those who sense if students aren’t very interested in the topic anymore and are willing to learn new strategies in medical education, who are concerned if students are overburdened with coursework, and who are genuinely interested in their well-being.

Finally, I believe that upholding a sense of mutual respect in medical schools redounds to better patient-doctor relationships in clinical and public health practice, and eventually impacts positively on the health outcomes of the patients we serve. For me, class attendance and the lack of mutual respect are not just problems related to medical education. They are public health problems. I choose to think that solving this problem sustainably addresses many health inequities and challenges that we face today.

In summary, I look at poor class attendance as a symptom of a deep-rooted concern: we need to strengthen the virtue of mutual respect. It is a concern for medical education, and more so, for public health.

How I wish we learn to address this soon enough. I still have one more long exam in biostatistics and I am hoping my class would #ShowUp and not flunk again.

Engaging people

Public health is essentially a field that requires engaging people. But in my years of working in public health I realized that engaging people does not only entail having to design policies and programs, and promoting them to the people who will benefit from them. Instead, I learned that I had to listen to the people, and cater to their actual needs.

These needs aren’t what you usually ask in relation to the programs one plans to implement. You don’t go out and ask people around their knowledge, attitudes and practices related to vaccination, for instance. What’s needed is knowing their context, their culture, and their daily life.

In my two years in the field, while implementing programs for preventing non-communicable diseases, I realized that the right question wasn’t about their attitude on taking maintenance medications. The right question to ask was what has been leading them to an unhealthy lifestyle. I’ve found that answers to this question come from precisely these: their context, their culture, and their daily life.

In the Cordillera region, for example, in my practice I’ve been seeing a lot of people with elevated blood pressure. I’ve come to know that this trend was not really attributable to the failure in taking maintenance medications. I also didn’t think that exercise was a problem: navigating daily the difficult terrain was more than enough. However, because of the Cordilleran preference for meat and salt, some of my patients not only develop hypertension, but also develop gout and kidney disease.

This is also similar to my experience with an urban poor health program, shown in the picture, where non-communicable diseases are related to food choices, as well as lack of safe spaces to conduct healthy lifestyle activities.

The clinical approach is usually to respond with medications. What appeals better to me is the public health approach: nip the problem at the bud.

In the case of my host municipality in the Cordillera, we instituted a program for monitoring blood pressure, blood glucose, and cholesterol, in cooperation with senior citizens and the local women’s organization. In turn, the municipal employees’ association and our nurses implemented a healthy lifestyle campaign that focused on increasing physical activity through zumba dancing. We launched the campaign in what would be the best date for cardiovascular health: Valentines’ Day, 14 February. The Department of Health has since implemented a similar approach nationwide.

Meanwhile, in the case of the health program with the urban poor, we trained health workers in monitoring blood pressure and vital signs, which is the first step in recognizing the presence of health issues in the community.

It’s a source of pride for me that my host municipality did it first in the province. I plan to go back and monitor its progress within the context of a research project, but with the pictures I see on Facebook, I’m happy the effort has survived after a few years. Similarly, the effort with the urban poor health program blossomed into a corps of community health volunteers. The long-term impact of our little training program remains to be seen and the efforts need to be sustained further, but I am happy it has impacted positively on the health-seeking behavior of the community.

All because of a genuine interest in the lives and well-being of people.

All because of engaging people.

What to research? A health policy perspective

Research is the real-world application of the “scientific method” which we learn in high school: after observing a problem, we come up with a scientific question, formulate a hypothesis, test it and analyze the results.

But it isn’t easy. Often, substantial resources and skills are needed to design a study, and more so to implement it.

In medicine, for instance, research involves clinical trials: patients are assigned treatment alternatives whose safety and efficacy have been established in previous studies, and their clinical effectiveness is assessed. In history, records are unearthed and accounts of various events are compared with contemporary documents. And in health policy, my field of work, it involves engaging with various health departments, interviewing patients, payers and providers; and investigating ways to improve efficiency and health outcomes for patients.

But in a country with meager resources for research, there is a need to set priorities for research, which not only optimizes the use of limited funds, but also responds to health needs.

Thus we come to this question: As far as health is concerned, what do we really need?

This is actually a difficult question to answer. A credible needs assessment requires a reliable health information system that collects data on what diseases are prevalent, what new diseases are emerging, how many people can’t pay for their healthcare, how much is healthcare, and other related questions.

I was of the notion that the rise of information technology (IT) and social media will somehow facilitate needs assessment. Yes and no.

No, because right now, individual health programs have their own ways of collecting data. My friends in the telehealth sector, a field of public health specializing in providing health services to faraway areas through IT, tell me that these programs need to talk to one another and agree on one way to collect data across all programs, to make it easier for policymakers and researchers to investigate causes that underlie health needs.

But also, yes. I know that the current difficulties in gathering information will be surmounted by just that one effort to integrate data collection and analysis. That way, we can ensure that the true health needs of the community are indeed identified accurately, and we know what indeed to research.

So, what to research? I say, it’s how we can know what’s really going on out there. The key is reliable health information.

Why health policy

Today I’ll be writing about the reason why I’m in health policy, which is a reseach-oriented field that responds to health needs through policy interventions such as laws, guidelines and rules.

For me it wasn’t crystal clear that it’s something I wanted to pursue as a career. It developed out of a desire to be helpful to more people.

It was a usual morning in my clinic. I was assigned as a municipal health officer in a mountainous region in the north of the country. I usually arrive in the clinic seeing patients already in line to see me, most of them having crossed hills and mountains to see me.

Normally, I try to greet them with a welcoming smile, looking forward to listen to their stories but also concerned about what ills have forced them to see me. I see the kindly old lady from the nearby village, following up for her usual blood pressure check-up, who greets me with a warm smile and an enthusiastic nod whenever I ask her to take her medications. I see a couple coming for advice on their family planning options. I see babies brought by their mothers for their vaccination.

Then I saw this middle-aged man, with impending doom written on his face, holding a plastic envelope containing various documents. It turned out that he wanted to seek advice about an important concern: how to pay for his hospital bills.

To be fair, the existing national health insurance system has paid for much of his bills. But he still had to pay for a few thousand pesos, which he cannot produce within the week alloted for him to pay his balance. I advised him that perhaps he just needed to see a social worker who can refer him to the proper channels for financial support.

But that was an encounter that got me thinking. I thought:

“What is the point of prescribing medications and treatment plans to patients who can’t afford them in the long run?”

I then realized that perhaps health policy was a good career after my stint in the health center. Not because it was a lucrative career option, but because I knew that I could at least work towards making sure that patients achieve better health because the health system works for them.

After my two-year experience as a municipal health officer, I received an invitation to apply for a researcher position at the Institute of Health Policy and Development Studies, a research institute under the aegis of the National Institutes of Health in UP Manila. With my director, I had the opportunity to do research on health insurance, health management and human resources for health, aspects of the health system which directly affect the health of patients in public health facilities.

Now, a few years have passed since I made the decision to pursue health policy as a career. I have been given the opportunity to present my work in some fora, gotten the chance to network with like-minded people and broaden my knowledge in dealing with complex health policy issues.

But I still wonder about that man who approached me in the clinic years ago. I think the best measure of my success as a health policy researcher is whether or not I have done something that directly impacted him and millions like him. The task is far from over. In fact, I think I’m just getting warmed up.