Monthly Archives: February 2014

Business Quote 4

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From an internal document of one of the greatest companies of all time: “We accept challenges with a creative spirit and the courage to realize our own dreams without losing drive or energy. We approach our work vigorously, with optimism and a sincere belief in the value of our contribution.”

From The Toyota Way by Jeffrey Liker

Interview: Mary Christine Castro, MD (Community Doctor and Policy Advocate)

Castro

We have introduced some of the leading medical specialists to our readers. We now turn to someone who has decided not to specialize, but has decided to use her medical education to serve and help solve the problems of the bottom of the Philippine social pyramid.

Sunfu: For those not familiar with your work, please tell us something about your background.

I work for the Nutrition Center of the Philippines, it is an Non-Government Organization  doing research on public health and nutrition policies. We design programs and projects that address nutrition issues in the country. I am currently its deputy director. Previous to that I worked for 13 years for the Community Medicine Development Foundation. It is another NGO that works to develop community-based health programs: that means we help empower people and train volunteers in the community to respond to the health problems and issues. We teach them the symptoms of the common diseases in the community and we show them home remedies that are possible and readily available in their area.

Sunfu: Is government failing in its duties? Are you not duplicating the work of government?

Health care facilities and personnel, especially doctors, are usually urban based. They are not in rural areas. The devolution of the health care responsibilities has also put a lot of the responsibilities in the hands of local government units; but before the local government code was enacted, there was already a lot of opposition from the health sector to the devolution because they anticipated many of the problems we now see on the ground. For example, the reality on the ground validates the anticipated fears that when a mayor is changed after the elections, there is no continuity of programs. A certain program is associated with the previous mayor, the new mayor doesn’t want to support the old program. This happens even at the barangay level. Health care is at the mercy of very local politics.

Sunfu: But the building is there. The medical equipment is there. The whole infrastructure for health is now there. Doesn’t that help?

Health Secretary Enrique Ona’s thrust is to upgrade equipment and facilities, so you are right. But a municipal health officer told me recently that the facilities and equipment may be there, but there are no additional midwives, there is no budget for additional people, and so the facility and equipment are not optimized at all.

Sunfu: Maybe Metro Manila is just too attractive? Maybe nobody wants to serve in the rural areas.

That is one of the problems. There have been efforts to address that problem before with the Doctors to the Barrios program of then health secretary Juan Flavier. They wanted to have doctors in 247 municipalities. But there are over 4000 municipalities. 247 is a drop in the bucket.

Sunfu: Is government failing? Where are they succeeding?

The Palo School of Health Sciences in Leyte is a good program. But aside from that and the Doctors to the Barrios program, I cannot really think there are many other programs that are innovative, high impact, and long-term in thinking.

Sunfu: We now have Philhealth, we now have provincial, regional, local hospitals. Is government doing its job? I have the impression we have moved forward a lot already, and significantly at that.

Yes, Philhealth is good: there are many issues still to be resolved and clarified, and with the sin tax adding to the budget, there is much optimism: but we still have to see its full implementation.

Sunfu: Is it possible to give a categorial answer: is the government doing its job or not?

In many areas I have been to, I don’t think government is able to fulfill its mandate. The health care system is not able to address most of the needs of the people.

Sunfu: I go around myself, and I am actually impressed by what the government has done: some local government and national government projects are impressive. Maybe the problem is not the government, but the problem is the talent is just too attracted to serve in Metro Manila. PGH has batches of its former students living and serving in the United States already. Maybe the problem is the aspirations of the doctors, not the government.

Yes, the education system is part of the problem, and not just medical education, but the whole education system. But what incentives are there to serve in the periphery? Our medical training is really for hospital care, dependent on diagnostics based inside the hospital. When I was still a medical student, we did not have enough public health subjects, there was little exposure to health policy and community health issues and problems. I heard this is changing and has improved significantly today in the University of the Philippines. In our time, it was largely hospital-based care that was emphasized. It is largely diagnostic and curative. It must be more holistic, more preventive and promotive, then we move from the diagnostic to the curative, but there is also the rehabilitative.

Sunfu: Is community medicine necessarily political?

You recognize that the political and economic will affect your treatment when you are in the community. For example measles, children are supposed to be vaccinated, but if you are malnourished, lacking in protein, your body won’t be able to produce the anti-bodies needed for the vaccine to work.

Sunfu: There is supposed to be a measles outbreak right now. Secretary Ona is getting a lot of flack for his measles program or lack of it. Former health secretary Jaime Galvez Tan is even quoted in media as having openly criticized Secretary Ona. What is your opinion?

It does make you wonder. The coverage reports of many areas for the measles vaccination are claiming 80 to 90 percent, so you wonder why there is a measles outbreak. I have not really thought of this issue in-depth, but the data about immunization area coverage has to be validated. The potency of the vaccine should also checked, and must be found to be beyond reproach. The whole chain of delivery of the vaccine from the place of origin to delivery to the patient must be closely examined. And a lot of places where there are power outages, this could also pose problems in the storage and handling of the vaccines.

Sunfu: You were part of Intarmed, the accelerated medical education program of the University of the Philippines: students in this program are supposed to be the cream of the crop. The best and the brightest among the best and the brightest. What happened that you did not continue to a medical specialization? The great fetish of UP-PGH graduates is to specialize after medical school, to go for some fellowship in some big brand school. This is almost a necessity, the way for some a handbag has to say Louis Vuitton or Ferragamo. What made you take another path?

When I was in medical school I joined a group called Pagsama: we went on medical missions, and that experience had a big impact on me, of seeing the many problems of our country and its people. I had a professor, Dr. Art Pesigan, and he invited us to join their activities in Mindoro and Nueva Ecija. We saw how they  trained health workers, promoted herbal medicine. When we graduated, we were encouraged to join them in their work. In our batch in UP-PGH, batch 1993,  some of us have gone on to work on community health issues: myself, Dr. Gene Nisperos, Dr. JP Leung, Dr. Ethel Tangarorang, Dr. Anna Rilloraza, Dr. Beth Riel.

Sunfu: Looking back do you wish you had specialized?

No, no regrets at all.

Sunfu: What would you tell Intarmed students now? Their parents have so much hopes for them to become big established doctors affiliated with the biggest brand-name health institutions.

If you look at the twin goals of the University of the Philippines, it is academic excellence and community service. The latter is not emphasized as much as academic excellence. The question everyone will eventually ask is why do you do what you do? For who? Academic excellence is good, it is very important, but there should also be responsibilities to the community and nation building.

Sunfu: Should we not be giving up on nation building?

Why? Because of globalization and the upcoming ASEAN integration?

Sunfu: No, I think nation building necessitates a belief in a national elite, then it means you have to create one and sustain them, hoping they will be enlightened and not have rapacious appetites. We also have to compete with other nations, and that doesn’t help at all in that we want solidarity rather than division. If we want a socialist or a more equitable society, we must give up on the idea of nationalism already.

Yes: but I believe that will come later, we have to work by stages.

Sunfu: I was telling Rey Casambre, during the wake of Monico Atienza of the First Quarter Storm Movement, after the crowd sang the International, they started to sing Bayan Ko: it was wrong in terms of sequence, and I believe nationalism has been the age-old albatross of the Philippine Left. I was surprised: he agreed. But let us move on from that contentious subject. Were you politicized in college?

No, it was in medical school, the medical missions were important to opening my mind and my eyes. Of course the US military bases issue was a big discussion point at that time, and that accelerated my politicization.

Sunfu: Do you have a political line?

Let us just say my motto is “serve the people.”

Sunfu: Do you meet medical students now in your line of work today?

Unfortunately right now no.

Sunfu: Are you critical of doctors who do research for pharmaceutical companies?

Research is important. If government has the funds, of course ideally it should be the government that should be funding research, aside from universities. People make personal choices. I would not persecute people for this. I respect the decision people make on this issue given the realities we all face.

Sunfu: What keeps you going?

It is fulfilling how people appreciate one’s efforts. Even as a clinician, appreciation from another human being gives one a big sense of fulfillment. In community work, in the poorest areas of the Philippines, even if you were there only for a short time, when you go back 10 years later, they remember you. They even have stories about you. It is a very fulfilling experience.

Sunfu: Sounds like it is all psychic rewards. Sounds horrible! (Laughter). Let us put this way: what would you tell a young UP graduate that advocacy is able to do that would inspire them to join advocacy and community work.

Looking back, when we were still students, the generic law debate came into our consciousness. That is a landmark government policy and eventually law, and a dramatic shift in the mind set of the medical community. Our professors like Dr. Rommy Quijano and  Dr. Isidro Sia, they had done a lot to inculcate this as part of the health policy and medical culture in the Philippines. They opened the minds of their colleagues and students. Advocacy is important. We need people to have choices. We need new ways of seeing the world. This is one example of policy and advocacy that really has a long-term impact on the lives of the poorest, without excluding the other sections of Philippine society from its benefits.

Sunfu: Does this mean you would not allow medical representatives in the clinics of doctors if you were health secretary?

Like the milk code, there is a struggle between milk companies and breast-feeding advocates.  Similarly, the pharmaceutical companies have the monopoly of the market, and we have to make people aware of the alternatives by having some kind of a medicine code, a certain limit on advertising and promotions. There has to be a limit in the entry of promotions inside a medical environment.

Sunfu: Who are best best public health advocates among the many secretaries of health you have seen?

Dr. Jaime Galvez Tan,  Dr. Manuel Dayrit, Dr. Alberto Rommualdez.

Sunfu: Secretary Enrique Ona, the current secretary of health?

Public health, preventive and disease control are not his priorities. These are my priorities.  Even breast feeding advocates within the DoH are said to have some difficulty in getting his support. Upgrading medical equipment and facilities, as I had mentioned earlier, is his priority. This also important, of course, but this is not my priority.

Sunfu: When I look at the public health budget and efforts of government doctors and policy makers, I really think the efforts are good and we are moving forward. Yet there are still so many health problems: where is the disconnect?

The economic system is really the problem, and we must note that even Pope Francis is saying that the current economic system, the trickle down economy, is not working. It cannot just be health per se. Majority of Filipinos are still mired in extreme poverty. There is a disconnect between the DoH and the regional hospitals. The regional level is really undermanned. In some regions there are only three people assigned for maternal health. With our high birth rates, imagine the need for people to be assigned and trained for maternal health. Then there is the disconnect of the provincial hospitals with the national programs. The Doctors to the Barrios program offered P25,000.00 monthly, for two years, to any qualified doctor who wanted to serve in the rural areas. We need more of that, and a program that goes beyond a two-year program. General Santos’ population has increased dramatically in the past few years, but the number of midwife positions in the past decade or more has remained constant in that particular area. Addressing poverty should be a multi-sectoral approach. A lot of the farmers still don’t own the land they till yet we are an agricultural country. Their system of planting is antiquated and inefficient. They need support, technology, and training. They need to own the land they till. People are not making enough money to address their basic needs.

Many municipal hospitals had to be downgraded after the devolution because there was no money to support higher level services.

Schistosomiasis, a worm that stays in the liver, is still a problem in Samar. It is still prevalent. This is an intestinal parasite, which means this is a problem of sanitation. This is a water and sanitation problem. This is not a simple issue that can be solved by a curative approach. People must be educated about this. The immediate host of this worm is a small snail found in rice paddies, in stagnant water. In these areas, people must be taught how to identify these snails, we must teach them to find these snails. There has to be vigilance in order to see where mass treatment is necessary. DoH says the drugs are there, but there is a problem of distribution, of education, of implementation.

This problem is multifactorial. The health services are not that consistent, the delivery of these services is very uneven. In order to treat all those who go to health centers for consultation, all health units must be adequately manned. A midwife in rural areas usually has to serve many barangay health units in the course of the day. Many of them have to move around all through out the day or week. Our strategy in community health and community organizing is we go to the community to have someone there who is trained, to have someone who is rooted in the place become aware of the problems and the possible solutions.

Sunfu: In your travels abroad, what did you see that you liked that we can adapt here?

There are aspects of Switzerland’s health system that made an impression on me. I saw a birthing clinic which is not hospital based. Giving birth is not a sickness: it doesn’t have to be in the hospital. They have nurses do home visits in the houses of the elderly. Switzerland is a very rich country, but I think we can do what they do in the community.  Health care is really a part of their community. Why can’t we do the same? With our great number of nurses, we should be able to do this.

Our education system is very much patterned after the US,  and so is our health care system. The UK has a better public health care system in that the poor have access to quality health care, in spite of the budget cuts happening to them now; certainly it is better than what they have in the United States. There are other models out there.

Sunfu: Please share with us a few books or authors whose books you love to read.

I love fantasy and fiction. For relaxation, I read Rick Riordan. The House of Hades is the last book of his that I read. It is part of the Heroes of Olympus series. I used to be very much into Roman mythology in my student days, so I like this series very much. I really liked the biography Ka Bel: The Life and Times of Crispin Beltran by Ina Alleco Silverio. The books of Dan Vizmanos about Philippine politics. The stories in Not On Our Watch: Martial Law Really Happened is a collection I hope the younger generations will read.