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.

My journey with #HealthXPh

I would like to thank people who attended the recently concluded Philippine Healthcare and Social Media Summit 2017 (#HCMSPh2017) held in Cebu last 25 April.
The summit, now on in its third year, is organized by #HealthXPh, a community of Filipino doctors with a common passion to promote social media as a means for health awareness and patient empowerment. 

But aside from the summits, actually, the main activity of this community is the weekly tweetchat held every Saturday night, where we discuss various issues and their impact on health and clinical practice. Unique with this chat is a refreshing friendly environment, a respite from the hierarchy characteristic of the medical profession. After all, more ideas spring out when people are open to express themselves freely.

Starting as an endeavor shared by a group of friends, #HealthXPh was started by endocrinologist Dr. Iris Isip-Tan, orthopedic surgeon Dr. Remo Aguilar, medical educator Dr. Buboy Tapia, and occupational physician and patient advocate Dr. Gia Sison. Eventually, obstetrician-gynecologist and community maternal health advocate Dr. Helen Madamba joined the fold. At every step of the way, #HealthXPh was supported with fatherly care and support by trauma surgeon and former undersecretary of health Dr. Ted Herbosa. 

Then late last year, through my inclusion in its regular rotation of tweetchat moderators, I became part of the group, and became its bunso, its youngest member.

Until now I’m awed at how I managed to be part of such a formidable cast of clinicians and advocates. How did it happen? I don’t know precisely. What I do know is that I have been participating in the tweetchats since the group’s infancy, and I just found myself gravitating towards their mission and the fun-loving personality that they share as a group. 

For me, participating in the tweetchat populated by global and national movers and influencers required a lot of chutzpah. But after receiving news about the first tweetchat in late 2013, I felt I just had to join the conversation. Having just ended my stint in the Doctors to the Barrios program, I developed a desire to share my experiences and learn from others as well. #HealthXPh was the venue I was looking for.

In the interim, I have been on and off with my participation in the group, having been busy with other matters. But I knew that the tweetchat habit was more than anything else as I eventually realized that my Saturday night was incomplete without it. It complemented the health policy research I do for a living, and more importantly, taught how to communicate my ideas effectively through social media. Most of all, it has become like family.

Thankfully, about late last year I had the opportunity to adjust my schedule and make time for the regular tweetchat, and develop a great friendship with its regular participants. Before I knew it, we were planning together for a national summit, that to my pleasant surprise they have been organizing annually.

It gives me a warm and fuzzy feeling inside that a national healthcare social media initiative began as a tweetchat organized a passionate group of friends, and that they have given me an opportunity to be part of it.

I share this story as an invitation to people who would like to contribute to the success of health care social media in the Philippines. Attending the HCSMPH is just the beginning. Join us in the #HealthXPh tweetchat every 9PM Saturdays, and let’s exchange ideas. Who knows, your idea might just be what our country needs to achieve better health!

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

 

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.

The Interview

(originally published 30 January 2009)

I just sat for an interview this morning.

Last night, as I stayed for the night in my friend’s condo unit, my mind was already filled with questions about my future and about what I am to do with my life after, God willing, I get my medical license and become a full-fledged doctor. I wondered if the decision I made earlier that day would finally answer those.

There had been an intense urge, since that day began, to do something that will change my life forever. I eventually felt this urge being satisfied as I finally walked in the scholarships office and signified my intention to apply for a unique scholarship program.

Admittedly, half of me wanted the benefits. These times are tough times for me and my family. Petty quarrels have been becoming quite frequent at home, because of how that very precious wad of bills is being spent. I felt badly that I had to do something about it.

Initially, I did just that by entering a business venture with some fraternity brods. During the past months I had built a business of my own, which was grounded on the principles of free-enterprise and private franchising.

But, now, it seems to me that prospecting and showing business plans occupies too much space in my already complicated mind. My ideas and feelings about building a business may change in the future, but I really feel that I have to focus. Right now I wanted to fixate my mind on this objective: To study hard, and become the best doctor I can be for other people.

This time, I wanted to find a way to augment the family’s finances without having to lose my focus in becoming a dedicated physician. With this in mind, I finally applied for a scholarship grant that will take me to a far-flung area right after passing the medical boards.

Yesterday I had been told that the interview will start at 7, and found the day opportune to staying for the night at a nearby condo unit of a close friend. Just this morning I readied myself, imagining what questions will be asked and what expectations are to be met. I tried to answer each question sincerely and with heart.

I told them how much I would risk to serve my nation. As corny and as patriotic this may sound.

I told them how much I felt ready to be part in building the nation one rural health unit at a time.

And I told them, that in the future, I want to establish a medical practice that will make my family and friends proud.

Right after I sat for the interview, I called my parents and thankfully I heard from them how much they supported me for a decision I made on my own: to pledge two years or more of my life to serving the underserved. I have yet to discuss these personally, I am still here in an internet joint across the college, searching for experiences of people who have trodden this path ahead of me. Some reassuring, others even discouraging.

But all of them, heroic.

I know, I am not yet leaving for an island town or a barrio nestled in the middle of the Cordilleras. But it is quite a different feeling waking up early in the morning and doing one’s daily tasks in the hospital while thinking of the future two years that you will spend in the barrios.

I have been told that the slot will be secured once my parents give me their blessing.

I can’t wait to talk about it with them tonight.

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EPILOGUE: I did get assigned to the Cordilleras. I have been at times doubting my motivations, even to the point of questioning myself why I did this. But after reading this and looking at the pictures of the areas I’ve served, absolutely no regrets.

Soul-seeker

“What is your specialty, Doc?” I got asked this question by a wide-eyed, enthusiastic third-year student in the medical school where I teach.

“I think I can call myself a public health specialist,” I replied.

“But did you take up residency?” referring to the usual post-graduate clinical specialty track taken up by majority of medical graduates.

I relented. “No, but I took a master’s degree in public management for health systems. I’d say that would be my post-graduate training.”

“Then, Doc, you are a soul-seeker.” He explained that he considered as such those medical graduates who have not pursued residency. I tried to suppress a look of shock. “I guess I am,” I replied.

What disturbed me a bit in that encounter was this realization: that, as far as majority of people I know are concerned, the choice to exclusively pursue an academic or research career after pursuing a medical degree is still considered a transitional career choice towards a goal of eventually obtaining a clinical specialization. I cannot blame them.

To be fair, he is not entirely incorrect. I had just come from an almost yearlong hiatus in my academic career, having come from a live-in vocation discernment program for men considering religious life. I ended up not getting accepted to the religious order I had desired, but my experiences in discerning my true calling bolstered my conviction that my calling is in the academe. Soul-seeker I really was, in this sense. But I digress.

That encounter made me think hard. By now, and especially after my yearlong discernment last year, I now have a stronger conviction for my career choice; that, instead of pursuing the conventional career path of clinical specialization, I am choosing an academic one. Instead of aiming to become a specialist in, let’s say, surgery or psychiatry, I am aiming to gather enough academic exposure and experience to earn a professorial chair instead.

My colleagues in the medical school faculty, majority of whom have finished their respective residencies, have told me that I can do both anyway. But for the past few years, I realized that, as a medical graduate orientated more towards a population-health perspective, going through the path of clinical specialization would introduce bias in the way I would do my public health work and advocacies.

This leads me to one instance three years ago, when my former research institute director asked me this question: are you geared towards specializing in ‘content,’ or in ‘process’?  He further explained that specializing in ‘content’ would mean studying all aspects of that field, exclusively, with the expected consequence of getting heavily invested in a topic. If that would be a field like road traffic injuries, that would require studying factors that affect it, its special considerations, its prevalence, and even how it affects popular culture.

My director told me that doing so for a particular field would open up a Pandora’s box, and would lure me towards studying the field further, and potentially ignoring other important public health matters. I’d now call it an option of getting attached to a particular topic. Nothing bad with this at all, he said, but it represents a lost opportunity to study about other health concerns that pose similar risk to the general population.

On the other hand, it is his explanation of specializing in ‘process,’ that attracted me. It meant that I had to specialize in a particular way of analyzing public health matters, like epidemiology, health technology assessment, or even philosophical analysis.

By specializing in epidemiology, the study of how diseases spread, I gain tools that can analyze how much of the Filipino population would be prone to any health risk.

By specializing in health technology assessment, I gain the skill of assessing which intervention would be the most economical and answer questions like these: for instance, would implementing a large-scale healthy lifestyle program lower down the percentage of the population suffering from high blood pressure, or a government-sponsored distribution program of medicines? What is the more economical option?

Finally, by specializing in philosophical analysis, I can explore how lifestyle diseases, or any health matter in general, can ultimately come from the individual’s ability to reflect on his daily existence, to make logical and ethical decisions, and make sense of his role in the world at large.

These three modes of ‘process’ that I have been exposed to can be applied to any public health topic, which makes it possible for me to affect the lives of people millions at a time. When I decided to pursue medicine, my goal was to help as many lives as possible. I now feel that by choosing to specialize in ‘process’ and not ‘content,’ I can potentially contribute towards solving any health problem by using a particular way of analyzing the problem. I just had to know what problem needs to be analyzed. This required frequent introspection, zooming out from the situation, as well as sensitivity towards concerns that impact the general population. I know that by specializing in ‘process,’ I am becoming the kind of doctor I want myself to be.

However, I also realize now where specializing in ‘process’ led me. It eventually led me towards an appreciation of discernment, and even led me to think that perhaps a life of continual soul-searching within a religious context was for me. But events and circumstances led me towards where I am now, and I was never this affirmed of where I am called to serve.

Notwithstanding, my experience in specializing in ‘process’ also points to me that I have to free and zoom-out myself enough so that I can serve as many people as possible: my personal definition of why I am a doctor in the first place. Needs and circumstances change rapidly, however. This inner search should therefore be a way of life. Specializing in ‘process’ led me to be what precisely that student called me that fateful afternoon: a soul-seeker.

This leads me to pay attention to what is happening in the Philippines nowadays. I think that we are beset by problems that are mostly resolved by focusing and getting heavily invested on the situation, instead of looking at it from a non-biased, zoomed-out perspective. My experience in public service tells me that government can only do so much within its means, but my renewed perspective in studying ‘process’ also reminds me of the value of unbiased points-of-view.

Moreover, I think that as a nation we need to have a better sense of our identity. Specializing in a particular ‘process’ of resolving matters of national importance is one part of making sense of this identity, but I think that we need to search for what is indeed our soul and our purpose as a people. I learned that one leads to the other. Perhaps we need more people who specialize in ‘process’.

In sum, I never realized that such an innocent question from my student would set me off towards rationalizing my career choice and my reasons for choosing ‘process’ over ‘content,’ and realizing how the study of ‘process’ requires continual discernment. Continual discernment requires that, imperfect as I am, I should have the attributes of a soul-seeker in good faith: resolute, passionate and untainted. These are attributes that I am not so sure now if I can confidently claim them for myself.

I take solace that being a soul-seeker was who I am in the eyes of that student of mine. I hope he is right after all.