Breaking the hiatus

It’s been a while since I was able to write anything on my blog. But for the past weeks, I’ve been very happy balancing my teaching with real world experience, both in the field and in engaging with health policy researchers and decision makers.

For instance, thanks to my friends in a health policy consulting firm, we are helping public health program managers develop integrative policies. In another project I’m doing, I am mentoring colleagues who are developing their skill in health policy and systems research in government health agencies. In yet another project with foreign colleagues, we are aiming to identify points for improvement in health financing in Asean. On top of these is my work with #HealthXPh and mentoring our community medicine rotators in an urban poor community in the south of Manila.

There has been so much to learn from my interactions from various collaborators, both within the country and internationally, that I have been very enthusiastic to bring the learnings back to home turf, in the college where I work. Melding these lessons with my own experiences in public health strengthens my drive even more. I feel a certain sense of responsibility to share these things to my students. I have to show that in aiming to serve the poor and marginalized, the way to go is to be ready to accept different views, insights and changes.

But, expectedly, change will be unacceptable at the start, just like the evoked feeling of unusual pasalubong that relatives bring home from a foreign country. Sometimes, the seeming initial rejection is enough to frustrate, even leading one to move on and look for more appreciative venues.

Nonetheless, this isn’t enough reason to give up.

Though I will agree that it takes skill and practice to pitch one’s ideas, change and progress have to be embraced. Change is never easy. Like how stressed aquarium fishes tend to get after the water gets changed, it’s understandable if one’s efforts towards increasing awareness and building self-reliance seem to backfire at the start.

This brings me to why I try to adjust the way I teach: the world isn’t getting kinder.

Five Filipino doctors, three in public health and two in clinical specialty fields, were killed within the past six months. These deaths may be due to a variety of reasons, but as someone who shared in their career paths at one point of my life, I feel that these deaths are a manifestation of how our health system is enmeshed with politics, governance, business and other seemingly unrelated pursuits, and how future doctors have to be well-equipped. Meanwhile, an increasing number of colleagues have been victims of doctor shaming, where doctors exercising their ordinary care and diligence are being berated on social media for various reasons.

We need doctors who will not rest on their laurels.

I believe that getting ready to practice in a world afflicted with these things requires a balance of versatility, proactivity and discipline. Those traits may well be cultivated in good class attendance, in diligently solving a biostatistics problem, or recognizing the merits of producing a creative work. Meanwhile, the lack thereof may well be demonstrated in cases in which health professionals would fail to provide the prescribed intervention to destitute patients, by not making do with limited resources, or doing something to address the lack. This is the kind of situation I would like to prevent, since lives hang in the balance.

Despite the odds, I am optimistic. I know it may be difficult for my students, but I hope this gets to them: we are in this together. I share in the difficulty, since learning how to be an effective mentor is difficult as well. Nevertheless, for the sake of our changing world and the patients we serve, the journey has to be trod. The good news though is we can moderate the pace of the journey.

But not too slow. The world and our patients anxiously await.

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

 

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.

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.