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

 

Decisions, decisions

In my tenure as a municipal health officer, there were two things that demanded much patience and diligent preparation.

One was whenever I would propose a project to the municipal council, in which case I had to write project proposals, talk to stakeholders and check with the budget officer, accountant and treasurer if my office still had enough remaining funds.

But for me, a more important and challenging task is this: deciding how to apportion the allotted budget for the coming year. It should be a well-informed and well-decided process, since a well-planned budget stands to benefit a lot of people.

The task of proposing a budget is one important application of decision science: what would influence an important decision, especially if people rely on it?

Another is deciding how much medicines to request from the health department. To give a backgrounder to this arrangement, in the Philippines, the funding and staffing of health offices at the municipal level have been devolved to individual local  governments. The national department of health (DOH) only provides technical assistance and augments resources by providing medicines and facilitating upgrade of health facilities.

One program the DOH implemented during my tenure was the Complete Treatment Pack program, in which medicines are packaged not by bulk nor individually; they are packaged with the goal of providing the complete course of treatment for patients, especially important for antibiotics.

For instance, a patient requiring amoxicillin, a medicine for bacterial infections, will receive enough medicine to complete the recommended treatment: three capsules every eight hours for seven days.

But this program has a list of drugs to request. For me, the difficulty of relying on previous health statistics to decide on this is the possibility of running out medicines if in case an outbreak occurs. This is why making decisions like this should also consider the context of the target communities: what are their potential exposures? What are their lifestyles? Would I have a good reason to get ready to treat many patients with non-communicable diseases?

Decision making is an essential skill in public health, and it should not just be made out of the desire to exert power: it should be based on what the community really needs.

Who is a barrio doctor

A few days ago, while mentoring junior medical interns doing their community medicine rotation, I received a text message from a fellow doctor-blogger. It wasn’t good news.

Jim pls check out FB and twitter another DTTB killed

Still reeling from the impact of the yet-unresolved killing of Dr. Dreyfuss Perlas, who graduated from the Doctors to the Barrios program one year after I did, I barely managed to keep my composure as I excused myself and caught up with the news. It turned out that the victim was Dr. Jaja Sinolinding, brother of DOH-ARMM secretary Dr. Kadil Sinolinding Jr. Dr. Jaja and his security escort were shot Tuesday morning, 18 April, by a gunman who had pretended to be a patient in his Cotabato clinic.

Notably, as news about the tragedy spread through news and social media, Dr. Jaja was tagged by DOH Secretary Dr. Paulyn Ubial as a “barrio doctor.”

Strictly speaking, at the time of his murder, he wasn’t part of the DOH Doctors to the Barrios program. He was an ophthalmologist who chose to establish his practice in Cotabato instead of putting up shop in more affluent areas in the country. His death has shown that the risks of serving the underserved do not only affect physicians who have chosen to join the Doctors to the Barrios program, nor those who became municipal health officers or rural doctors. It affects all health professionals, regardless of one’s specialty, as long as one has chosen to unflinchingly stand up for what is right.

Notwithstanding, in my opinion, amid the horrific circumstances of his supreme sacrifice and despite his specialist affiliation, Dr. Jaja has affirmed what it really takes to be a “barrio doctor.”

By choosing to put up practice in the provinces, he shared in the commitment to provide care to the underserved, despite the risk. Dr. Jaja provided free consultation services, and, as affirmed by people who worked with him in Cotabato, was a well-loved doctor.

By choosing to consider medicine as service and not a means for personal profit, he shared in the commitment to ensure that health is accessible to all.

Finally, by choosing to serve despite existing threats, he exhibited unparalleled courage.

Definitely, he was a barrio doctor.

A barrio doctor who, along with Dr. Perlas, deserves swift justice.

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.

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.