“It is not the man who has too little, but the man who craves more, that is poor. ”
Abhijit Banerjee, Esther Duflo and Michael Kremer won the Economics Nobel Prize. It is “their experimental approach to alleviating global poverty” that is recognized by the Nobel committee. Development economics has many factions and debates, and the “randomistas” have their many critics, as this movement’s advocates are called, for their adherence to randomized trials, just like in medicine, to do specific and highly localized studies to see the impact of economic programs.
(This link is a great introduction to the critique of the methodology of 2019’s winners) https://www.opendemocracy.net/en/oureconomy/impoverished-economics-unpacking-economics-nobel-prize/ )
We would like to point to their efforts at poverty reduction in the area of immunization. (See: https://www.povertyactionlab.org/evaluation/improving-immunization-rates-through-regular-camps-and-incentives-india ) Immunization from diseases is one of the cheapest and most effective anti-poverty approaches to helping the poor, as diseases punish the poor for their economic standing more than anything can, and to have a sick child in a family depletes whatever else the poor may have, preventing a move out of extreme poverty.
The Dengvaxi scandal has set back immunization efforts not only in the Philippines, but globally, feeding the anti-immunization movements with more energy than fraudulent data or pseudo-science has done. There is no need to discuss medical equipment placed in remote areas where there are no doctors who can use them, as that seems more obvious in the waste of resources. The immunization issue, or the Dengvaxia scandal, has focused largely on how dengue has come back to us in its seasonal surges with incredible vengeance, but that polio, that has largely disappeared, is back. But what is not told to us are the stories and data that will show, the misallocation of resources did not just hurt the poor with diseases, which endangers the whole global community (many countries are now starting to require proof of polio shots), but that those who are poor have become poorer, not only because of the sickness that has come to haunt the homes of countless families, the delivery of vaccines has become more expensive, with the need to allocate resources for campaigns to reverse the misconceptions about vaccines. The the low uptake makes the distribution higher in cost as well, as has been pointed out by this year’s Noble laureates in economics. (See: https://www.flipscience.ph/health/dengvaxia-scare-philippines-i/ )
It is a good reminder for those of us in health care, its many moving parts: technical, policy, business, politics, logistics part of this incredibly complex industry, because it is an industry: we are all chasing numbers, and multinational behemoths constantly pushing for quotas not annually, but quarterly (every three months) must be re-calibrated.The technological advances in medical equipment and wonderful new breakthrough drugs are not in question: it is our chase for numbers that have made the poor so much poorer, and no one wants to talk about this.
We came to the startup movement through Steve Blank: he really has it canned, this how to build a business from nothing. It is almost like it is too easy, except he does tell you, whatever else you do, starting a business to scale will probably be the hardest endeavour you can ever do, and by the way, coming from a dysfunctional family helps if you are going to be a founder. In fact in a panel discussion at the 2018 Lean Startup Conference in Las Vegas, Eric Ries the author of the bestseller The Lean Startup expressed his wish that if he could do it all over again, he would have not made it sound too easy, which has become an entry point of criticism for the book in recent years, especially now that corporate America is trying to implement and learn from Ries and his team.
Eric Ries’ The Lean Startup book and company we can say are the crystallization of Steve Blank’s initial ideas as taught in his classroom and initial blog essays, combining it with the engineering methods and management systems of Toyota, thus transforming the concepts and anecdotes to a combination of Steve Blank and Toyota into a digestible language that has graduated into the world to consultants and annual conferences.
First off, in spite of the criticism the Lean Startup concepts and simplifications have received in recent years, our company is a testament that the ideas of Steve Blank, and the iterations of his ideas in the works of people like Eric Ries do work. We of course are no brand name in the startup movements that have sprouted all over the world in the last decade, especially those that have emerged from Silicon Valley. But we have grown from our beginnings of just starting as a scrappy two-people team, to a health care trading company contributing to health care solutions in the Philippines. Nearing our one-decade birthday anniversary in the market, to pull back and understand startups, to be reminded of our roots, to also take a break from the intensity of work for eight years: we decided to join the Lean Startup Conference in Las Vegas.
Largely, the venue of having it on the Zappos Campus is very interesting, because startup movements are always seen to be innovations in technology, and Zappos is a testament that innovations can come from business models, service orientation, to management styles. Zappos is the largest company to practice holocracy, which we find to be too utopian but nevertheless seems to be working for this Amazon subsidiary.
The conference did not disappoint: the plenary sessions were mostly of very high quality, and the breakout sessions we thought were revealing of the limits of the Lean Startup concepts when extended to philanthropy or big business. GE previously was touted to be the company that was using the Lean Startup methodologies, and the difference of just two years in the covers of Bloomberg below should be enough to summarize what had happened in 24 months since celebrating the transformation of GE to some kind of a Lean-agile-digital company.
The big incentive for us to travel was also Reid Hoffman being part of the culminating plenary session, and he had approached business ideas previously with his background in philosophy, and his success in business and philanthropy made him a much sought-after speaker.
So with what Steve Blank’s ideas have contributed to our start and growth (we got to meet him and even had him autograph a book in 2016), thus the interest in Lean as a concept, Reid Hoffman attending to join a discussion on blitz scaling, and going to Las Vegas to visit Zappos: we were on our way.
Reid Hoffman is too big, and too present in youtube, to be interesting because what he said in the conference is basically out there already. And since he is a certified billionaire, he is likely very calculated in public discussions. This was all confirmed in seeing and listening to Hoffman on the last day of the conference. But in conferences like this, it is not the big name one is likely familiar with that makes attendance worth the effort. The discovery of new names not in our radar is really what makes these conferences worth the trip.
What we said about Reid Hoffman we can say the same about Tony Hsieh, what he had to say had been said by him many times, and easily can be found on the web, in articles and videos.
Hands down, Holly Liu was the best speaker for us, plus an education on the world of online games. She was articulate, staggering in achievement, and generous with her ideas. In fact, listening to her explained to us the weak breakout sessions or even one of the weaker plenary sessions. She basically says that there are abilities and ingredients to innovate and disrupt that are unique to startups. Some of the reasons are: nobody cares about your startup, nobody knows or likes your startup. This frees you up to be sharp, to be adventurous, and to dare to be different and exciting to rise above the rest. She did not exactly say large companies are hopeless in the areas of innovation and disruption, but that somehow the outlook will be different, or the ingredients just cannot be duplicated, and by implication, likely will need a whole different set of ingredients. In breakout sessions of the people in government who are currently tasked to bring in the spirit of the Lean Startup movement into these mammoth organizations, one does hear some of the speakers say they were hired because they did a startup and failed, so one qualification was they have tried out the startup world. There is much that has been said of being unafraid to fail in Silicon Valley, but the ability and the experience of those who have succeeded, like Holly Liu, are the reasons the gravitas to talk about innovation and persistence amidst the sea of failures is so convincing and more importantly, realistic.
The other great speakers were Matt Johnson of the Frontier Project and Stephen Robert Morse of Observatory, on the importance of a compelling story, even biological and psychological reactions to it were discussed, with a powerful preview of a possible Netflix project by Morse on Colin Kaepernick. Liz Jackson of The Disabled List (she was even more compelling here than in New York last year with her 99U talk on design as she argued not for design this time, but for how business is doing it all wrong in approaching this segment of the market). Joel Spolsky of Stack Overflow did not only have a great story of making it in the world of online business, but more importantly he talked about countering a web business that monetizes what should be an online space that allows programmers to have a free and open discussion to help each other. In short, not everything should be monetized in the web, even if it is possible to monetize it: and Silicon Valley is under the microscope these days precisely because of this issue (Facebook is monetizing you).
The discussion titled Lean Startup Where You Least Expect It was well moderated by Hisham Ibrahim, and the founders Malcolm Handley of Strong Atomics, Jaya Rao of Molekule, Greg Piefer of Shine, and Claudia Recchi of EdSights were all articulate, and have been going through the hoops of running a startup. These are founders who are beginning or have attracted funding, but are still grappling with issues of how to scale. You could see and hear their passion and struggle to get not only proof of concept, but beyond, the struggle to scale in the area of nuclear fusion to software to help universities track students at risk of dropping out. This is in contrast to the Real-World Lessons in Scaling Innovation Inside Large Enterprises with Keith Berry of Moody Analytics, John Buhl of Liguori Innovation, Julie Foy of Proctor and Gamble, Jean Vernor of Munich Reinsurance America, and Lisha Davis of Vanguard. The most memorable anecdote here was how Procter and Gamble innovated with what is a leading sub-category product in the diaper category: the environmentally friendly disposable diaper, which is certainly important, but also maybe says a lot about the limits of what is possible in giants like Procter and Gamble, which certainly is known globally to aggressively recruit some of the best talent available out there, but is also being questioned in media outlets for how competition from smaller companies may be beating it in the area of innovation and in delighting customers.
Forms were given to those who wanted some time with Eric Ries, founder of the Lean Startup Conference. It was told to us that those who will get some time with him will be announced, but no announcement ever came, so some of us wondered if this did push through. Our question written in the form was: How do we bring this to the Philippines? It was a shot at having the Lean Startup team really connected to Philippine giant companies (with paid fees of course, and we would have helped in the legwork to get them connected), and to the small but real startup scene in the Philippines. Telecom conglomerate PLDT for example had Guy Kawasaki previously, and we think other conglomerates are also trying to understand the startup DNA. Metro Pacific and Ayala Corporation both have startup funding ventures looking for the next Alibaba. It will not be as exciting as say trying out the methodology and the Lean Startup team in say Procter and Gamble, or even GE for that matter: but with the efforts in non-profit, I think to launch this in a Third World country, in Asia, will add to the coffers and glamour and usefulness of the Lean Startup ideas, extend concepts, ignite new movements. But the Lean Startup team will need to be willing to see this market as worthy of its time (China and its cities like Shenzhen should be disqualified from the Third World category), as it tries to extend its influence way beyond the Startup world of say San Francisco, New York, and Berlin. The future of this movement and the Lean Startup team of Eric Ries can be found outside the centers of startups and innovation.
A full disclosure: we got to attend simply out of the kindness of the Lean Startup Conference rules, that allow participants who find the fees too prohibitive to go at a much reduced rate in exchange for a blog review of the conference. The conference is worth the trip and the time for anyone who wants to know how people are using, innovating, extending the Lean Startup concepts. Eric Ries did proudly say at the beginning that this conference had none of the PR-machine-polished talks, and except for two of the biggest names that had the feel of a PR polisher having done work already long ago, Ries was largely correct, and this made the weaker parts of the breakout conferences all the more obvious, but at the same time it was what made the strong plenary sessions so fresh and compelling.
We had a leadership meeting yesterday and we had a discussion of the graduation speech of the late young genius: David Foster Wallace. If you have twenty minutes, it is worth your time to listen to the audio that is available on the internet. It starts out with a parable: Two young fish are swimming when they meet an old fish going the other way. The senior fish asked the two young fish: “Good moring boys, how is the water today?” After swimming for a while, one of the young fish turns to his companion and says: “What the hell is water?” The quote below is the key take away of that parable, which was the point of our leadership workshop.
According to the Department of Health website, former Secretary of Health Paulyn Rosell-Ubial “is the daughter of former UP Professor Neon C. Rosell, and she finished her primary and secondary schooling in UPIS. She he took up BS Zoology in UP Diliman, and Medicine in the University of the East- Ramon Magsaysay Memorial Medical Center. Subsequently, she continued her studies, fulfilling her postgraduate internship in the UP-PGH and her Masters Degree in the UP College of Public Health.” Academic qualifications hardly give us an idea as to the scope and depth of experience of former Secretary Ubial in the bureaucracy and in solving the country’s health concerns. We usually only remember the importance of the Secretary of Health when a health crisis erupts. Ebola, AIDS, measles, name it, when it hits the headlines, we remember who is our current Secretary of Health. We got an interview with our immediate former Secretary of Health, a long-serving civil servant, largely wanting to talk only of evidence-based decisions of policies and nothing else. That creates problems, in a country highly political and highly politicized, which may explain her non-confirmation at the Commission on Appointments, but for sure, we have concluded, the country needs more policy wonks and bureaucrats with their heart like Secretary Ubial.
How long was your service in government Secretary Ubial?
My anniversary of entry was October 30, so it was a total of 29 years.
You are effectively out of government now?
Yes, because when I was rejected by the Commission on Appointments, I was effectively separated from the government.
Does this mean your are enjoying your GSIS already?
I can only get my GSIS at 60, so I have five years to go and I have to find something to do while I wait, and I am seeing academe and advocacy as avenues for productivity in the next five years. Government can rehire me as undersecretary, and there are offers of consultancies, but with all the controversies due to the Dengvaxia case, my husband and I came to the conclusion that it is best not to go back to government. I am working with the Philippine Council for Population Development, an NGO working on the population issue, and I hope to work with the UP College of Public Health. I am done as a permanent or regular employee of government.
You have worn a lot of hats in government, but which would you think is the hat that adequately describes who you are, you are most comfortable with?
I would like to believe I am public health advocate, meaning I advocate interventions that will prevent illnesses and premature death. Unlike clinicians who help people one at a time, public health advocates, when successful, can affect millions of lives at one go. I advocate vaccination, seatbelt use, cessation of smoking, road safety, suicide prevention. Bringing down firecracker injuries is always a challenge for secretaries of health, and during my stint in the department I am gratified to have been able to help bring this down by 70 percent the injuries for 2018, the first dramatic drop in 10 years, so from a stable rate of 1000 injuries per year, it went down to 300. Zero unmet needs for family planning facilities. Anti-smoking advocacy. The list goes on as to what the department is doing, and what I have been involved in.
Which one of your advocacies are you proudest of?
I was the head of the polio eradication unit when we staged one of the most successful national health programs: the Oplan Alis Disease. We were declared polio free year 2000 and Secretary Romualdez received the award in Japan. I am very proud of being part of that.
You mention Secretary Romualdez, considered one of the best secretaries of health of the nation for the germ of the idea of universal health care, which became Philhealth.
Definitely Secretary Romualdez is remembered to be one of the greats. The backbone of Philhealth and the idea of universal health care in the Philippines was indeed due to Secretary Romualdez. It evolved with Secretary Dayrit, another great Secretary of Health.
Another great perspective of Secretary Romualdez is we cannot reinvent the system, but we have to work with the existing system, so he had the vision of improving our health care that assumes that 50 percent is private and 50 percent is public, and he gave the vision to unify it with a national health program, so even if an indigent can walk in the private hospital. And if you are a private sector person, you can walk in a public hospital and get equal quality services. It is happening slowly now.
But it is also in the records that Senator Juan Flavier was a great public health advocate, and for me the greatest Secretary of Health of all time because his humour, jolly nature, his style really motivated the health workers to be productive. He was not a seasoned policy person, but his infectious personality, he was able to mobilize the program managers. I was with the immunization of polio during his time as secretary, and I consider that some of the best times I had in the department. He brought out the best in the people of the bureaucracy.
These are the top three I have in my list: Flavier, Romualdez, Dayrit.
The bureaucracy of the government we must value, we must hold dear, but it must be given the correct moral compass, and its leaders will determine that, as we have seen, with Flavier, the DoH people shined, values of efficiency and integrity really came out, proving once again that the people will only be as good as their leaders.
Your only child, a son, is now studying to be a doctor. Would you encourage him to enter government service?
It is very productive to be in government. I was with Gina Lopez and Judy Taguiwalo recently for lunch in Gina’s place, we realized we have done a lot in spite of our short stint in government as secretaries of our respective departments. You have the resources, Judy was saying, to really make an impact. It really has an impact on the marginalized to do things at the national level. Gina Lopez and Judy Taguiwalo were never part of the national government, so they saw the scope and reach of the national government. Before DSWD, for an indigent to get funds, a person must go through a patron or a local politician, now that is not needed anymore in DSWD or even in DoH. You just have to prove you are an indigent patient and you will be helped. The PDAF issue was an eye opener and a jolt to the system to move to a higher level. So there are many good things happening still in government.
The salary now is also competitive with the private sector. We benchmarked with government-owned corporations. With this, I encourage doctors to apply in government not just for training, but for a long-term career.
Government is still okay, so the short answer is yes, I do tell my son about government service, but it is his choice, it his prerogative as it is after all his life. His choice of a career in medicine is not because of us. It’s his life, we tell him that. He almost went into law, since he was a part of the debating team when he was studying BS psychology for his pre-med, and he was practicing on his father and mother at home for his debating skills (laughs).
Politics is intense in government?
Yes, but politicians and legislators are realizing they should not be in health, and that patronage politics should stay away from it. The recent controversies hounding our health initiatives and hampering our health initiatives are a reminder that the department is best left to professionals, bureaucrats, technocrats, policy people.
Maybe not just politicians but the Church?
In the issue of the Catholic Church in reproductive health, they have their dogmas and tradition. They have their role to play in all of these.
The Department of Health however must base its policies and decisions on science and evidence. Religion and science need not clash over policy. There is actually no conflict, or there should be no conflict. We are advocating birth spacing as a department. Birth spacing is a response to health issues, not just economic or demographic issues. Of course when you have the numbers you want, you should have the option to spacing and limiting birth. The Dpeartment does not try to control birth.
In our HIV AIDS programs, we work with the parish churches to promote abstinence, healthy lifestyles, and when all else fails, go to the health centers (laughs).
South America, Columbia and Brazil have successful population policies and they are largely Catholic countries.
The earth can hold around 15 billion. We are half that already. We really need to think of the population issue, because in 20 years it is an issue we will be forced to confront if we do not tackle this now. 2.1 is replacement growth for the Philippines, and we started with 6 in the 60s, now it is around 2.6 already, so by 2022 we want to achieve replacement level growth of 2.1.
The Health Department has a very strong anti-tobacco company stance. Its code of conduct simply makes it impossible for both sides to work together even for worthy projects. The pharmaceutical industry that has produced great discoveries and inventions are more the challenge. What should be done?
I agree, with pharmaceutical industries, it is more challenging. We have a code of conduct, but in the Dengvaxia case, you see the code of conduct would have worked, if followed, followed strictly, and there were obvious lapses the hearings and investigations are now showing. We need these investigations in order to correct the flaw and lapses. The FEC (Formulary Executive Council) and FDA (Food and Drug Administration) were compromised and we have to study this and learn lessons from that. The safety barriers and safety nets are enough if followed, as the guidelines and laws are in place.
One very important realization for the bureacracy, that since we have the money, we have the people: we must conduct our own clinical trials and studies to validate what is out there. We must form an independent research culture that is sustained and supported solely by the government. That is the big realization for me as Secretary of Health, and that is what the Duterte administration has shown us: that the government has the money. The country has the resources to do grand and ambitious projects and undertakings. We are proposing we do our own studies with RITM, UP, San Lazaro.
Other countries just increase sin taxes, but we allocated all our sin taxes to health, and not all countries do that. During the time of Secretary Ona the guidelines of the DoH was that 2 percent of our budget should be given to research and we have started to implement this during the time of Secretary Ona. Sin tax has given us the elbow room to outsource to academe. The need for research that the government totally control and is funded well is now considered not only important, but urgent.
You sound optimistic about what the Duterte government is doing in health, but what problems are we facing in actuality. I could imagine it must be still gigantic, considering the problems we are hearing about like the Dengvaxia controversy.
30 percent of our people are still not covered by Philhealth, that is 30 million: so we have some way to go to reach those in the hinterlands for example, those in disadvantaged areas, prisons, informal settlers, we still have a way to go. In my stint as DoH Secretary we call that the last mile we have to reach. But you are right that I am optimistic: our focus is the population that has no money for not just the hospital, but catastrophic we cover 80 percent of the medical expenses after the 20 percent of Philhealth. The president even added 2 billion for this. It is the collateral expenses, like transportation, that is also a problem. The DoH is trying to figure that out as well.
We have a president in President Duterte that is focused on health and education. We rose from 122 billion pesos including philhealth to 142 billion pesos in budget, and now it is 164 billion. It is the biggest increase in the budget of DoH. We were able to implement a lot of the programs, and more are in the pipeline that Secretary Duque will implement and have the vision and skill to execute. Immunization the previous budget was 3.2 billion pesos for vaccines, now 7.2 billion pesos is for that.
Our policies should just be guided by evidence. Secretary Duque will be reintroducing metrics and score cards, which he started during his first term as Secretary of Health, but that effort was waylaid by so many initiatives like the ISO to improve systems and documentation. Of course that gave us guidelines, and that is also good for quality, but metrics and scorecards give accountability and Secretary Duque will do well in that.
Before the national insurance circa 1995, quality as a concept was not institutionalized, so metrics and quality systems were needed to go beyond just the idea of service, but quality is a word needed there too. It cannot just be service without quality.
Yet we must see the statistics: There is a gap of 42,000 beds. We have one bed for 2000 Filipinos and the ideal is one bed for 800 Filipinos. Only in Metro Manila is it one for 591. I think that is a little off because I don’t think they factored in the high migration into Metro Manila in the mornings from workers and students coming in from the surrounding areas.
Any models outside the Philippines we can learn from?
We need a cadre of health workers, and since we can afford free university education, then we can hire health workers with a good salary. We deploy them. So for every 1000 Filipinos, like the Cuban model, there has to be a doctor monitoring them. We can have a nurse instead of a doctor and it will still work well.
The outcomes in Cuba in infant or maternity mortality are better than the US or any developed country, so 460 dollars per capita is invested in health in Cuba and in the US is 8000 dollars per capita, but it is the ratio of health workers taking care of a population at the preventive level that is the key. The system can prevent illnesses, and the Cuban model has a very strong primary care line of defense, so if you don’t come to the health facility, the doctor will go to your house. You have no choice but to get healthy. We see people in the streets in the Philippines with tumours in their face as big as a basketball, and that is because no one is getting them to a doctor, and this can easily be detected when the tumour was still the size of a marble.
Any teacher inspired or helped you in a big way when you were a student?
Joven Cuanang. Many teachers helped and influenced me, but he is the most memorable, and a brilliant artist as we saw when he drew the brain, as we did not have power point or transparencies then, so Dr. Cuanang would draw the brain in front of us when he was my teacher in anatomy. He is retired now and we still see each other occasionally.
How about books? Any you want to bring to the attention of our readers?
I like reading autobiographies, life stories, and it reflects my being a government personnel for so long that I have read the autobiographies of our presidents, especially from Marcos to the present, I have read them.
If I have to single out an author, I enjoyed and learned a lot from the books of Senator Juan Flavier. This again reflects my great admiration for him as a man, and for what he has done to our Department, and his contribution to our country.
Is there anything you want to say about the Dengvaxia experience of our country?
On my thoughts on the dengue vaccine, this was what I told DOH program managers when I learned about the pilot implementation happening just before the 2016 elections and the targeting of one million grade 4 school children: “Even if it were a good vaccine, no long-term safety issues, the fact that it is introduced before the elections, it will already be tainted, its rationale and purpose will always be doubted.” It was doomed to fail even before it started and the low uptake of only 67% of the target population is proof enough that the social preparation was not adequate and people had doubts as to the vaccine program’s real intention. It was problematic from the start, even before Sanofi made their announcement of a label change on Nov 29, 2017, which just confirmed the people’s doubts, because that vaccination campaign was rushed, even introducing it before completion of the phase three of the clinical trials. I was caught in a damage control situation, damned if I continued it, damned if I stopped it because 2.5 billion pesos worth of vaccines were already in our vaccine storage facility in RITM, and at that point the ADE (antibody-dependent enhancement) risk was only theoretical. Then all the pressure from Congress came in. It was a difficult time but I did all decisions with consultation and due process, plus there were an Expert Panel recommendation, Execom Resolution and an FEC imprimatur.
“Let us prepare our minds as if we’d come to the very end of life. Let us postpone nothing. Let us balance life’s books each day. … The one who puts the finishing touches on their life each day is never short of time.” Seneca
Mark Richard Kho, MD is a General Surgeon and Surgical Oncologist, a VP for Medical Service Operations at the Manila Doctors Hospital, and an educator at the University of the Philippines College of Medicine-Philippine General Hospital. The interview we had in his clinic was interrupted by calls from worried patients and relatives of patients, trying to find words of reassurance or ways to beat cancer, the disease described in a New York Times bestseller book, and titled as such, as the Emperor of All Maladies.
Sunfu: Are you into research Dr. Kho?
Yes, having had to spend about 2 years doing actual bench work in a basicscience/cancer biology lab in California as part of my Surgical Oncology fellowship training, where at least 100 PhDs work within the campus. Being in the academe here in the Philippines, research is indeed a key thrust,along with training and service. But what research we are involved in ishardly cutting edge as we don’t have the infrastructure support for suchkind of research in our country. It is hard to match the billions of dollars the US government pours into cancer research annually thru its National Cancer Institute. Still, US researchers are clamoring for more dollars. We of course do not only need logistical resources, but human resource as well, and with our diaspora, we have a dearth in this area. So Basic Science research may not be for us, as we do more of clinical research focusing on the local setting.
Sunfu: I think you may have the most well-appointed private clinic here in the Manila Doctors Hospital (MDH) and judging by the looks of this place, you must be getting a lot of support for your private practice.
I do and am so grateful for the challenge and the opportunity to participate in the MDH vision. And thank God for it as well, because at the PGH where resources are already scarce, we are hardly compensated for all medical, administrative, training and research work. MDH, under its new and dynamic management at the time when Metrobank Foundation came in, was one of the first to provide much needed support for private practice to physicians by renting out clinic space and access, rather than the old modus of selling clinic privileges requiring millions of pesos in initial capital from physicians. And with the ever-increasing demand of the acquisition of new and capital-intensive medical equipment, the MDH management principle of plowing back whatever earnings from hospital operations creates an environment of financial sustainability, growth and better health care service to our needy community.
Sunfu: Should we have medical research in our country?
Yes, because the Filipino profile is different, our diets and locale are different, and we need to have the data to compare ourselves with other populations. The challenge is in prioritizing research over service with our limited resources. A quick albeit temporary solution will have to come from the philanthropic or business sector of society in providing the much-needed funding. The more permanent and appropriate solution is to have government and/or legislated funding. Essential to this is making health care a major budget concern.
Sunfu: Was your training abroad helpful?
Definitely, honing one’s competence can only be helpful. To be formally trained in places where skills and technology are at the forefront of my field gave me confidence and proficiency. Such a learning experience gave me a richer perspective, and sometimes perhaps an even vastly different perspective, as these medical centers outside the Philippines have a different profile from the patients we managed as students/residents in medical school.
Sunfu: If there is a patient who has the money, should the patient go to the US for treatment?
For the more common cancers like breast and colon cancer, like what all your interviewees in your company website have said, we have the available the standard treatments as they have abroad. Perhaps the machines are not as fancy or the “latest” models as the machines they have, but the bells and whistles of the machines may not add anything if what we are talking about is the survival of the patient. The bigger problem most of the time is whether the patient has the resources to go through the whole treatment cycle. What we lack here in the Philippines is the option of providing the patients the chance of participating in clinical trials due again to the lack of research funding.
Sunfu: What did the young physician, Dr Mark Kho, not know that you know now as a more senior doctor?
After medical school, I did surgery residency for 5 years, then another 5years of Surgical Oncology training in the US, and it’s been 19 years since I came back. There have been a lot of advances in drug development andsurgical techniques. And with all these years of experience, you learn better patient management. Also, because of the increase in patient interaction and relationships developed, there is a corresponding increase in one’s sense of empathy.
Sunfu: What do you tell your son who is training to become a doctor?
As my dad who was a surgeon often told me, I would tell him that as he increases his knowledge base and skill set, and as he becomes more competent, empathy should always still be there. Expertise without empathy will make him fail as a doctor.
Sunfu: Dr. Mariano Kho, your late father the surgeon, what did you learn from him?
I learned a lot from him. He was my doctor, teacher, mentor, and friend who always had my back. I miss him a lot, and his most empathic advice to me was to be of service to others and to remain true to what I trained to be, which is to be a medical doctor and surgeon, to not be distracted in the end by other additions such as politics and running for positions and government posts. Being called for administrative and academic work is a bonus which enhances my service to the community to which Dad has therefore encouraged me to take up to the task. He always reminded me that I am first and foremost a healer who can provide some comfort to his fellowman.
Sunfu: But since you are in your 50s, are you not tempted to go wholesale rather than retail? Won’t you affect more lives if you do good work as an administrator or maybe a policy adviser?
Sure, but then precisely because that temptation is there, that is why my father believed he must warn me about shifting focus. It is an art to manage one’s time, and as one who can be called on by patients almost any time, there is already not enough time in a day. But that is my identity, that of a surgical oncologist. There is a lot of temptation to move on, to leave my practice and direct patient care behind, but I know this is what I trained for and this is who I am. So as much as I can still do with my steady hands and good eyes, I will do so. On the other hand, I have been so fortunate to be able to help, in the little time and small ways that I have, in administration and policy making at MDH, the University of the Philippines and the Philippine College of Surgeons.
Sunfu: What did you learn as an administrator of a hospital?
When you are in administration, you see the complexities and difficulties of running a hospital. Since my parents and siblings and some in-laws are doctors, people say that we can already man a brand new hospital without any nuances. But now I see it at the vantage point of being in administration, and you realize that a medical degree even combined with an MBA may not mean much. It doesn’t mean you can run a sustainable enterprise, which is necessary to be a good hospital. It takes investment in time, bold effort, sharp managerial skill, a lot of common sense, patience, luck and opportunity.
Sunfu: Conglomerates are entering the hospital industry, is this good?
It is a difficult question to answer as the experience is quite new and we are not privy to all the motivations and intent of these events. Certainly, the systems efficiency is increasing. Capital investment capability is also becoming more robust as more conglomerates enter the industry, enhancing the sophistication in negotiations and bulk pricing, so that acquisition at good prices means more opportunities to buy better and modern equipment. But of course, as we see business people contributing greatly to the success of running hospitals, one also appreciates the need for medical doctors to be an integral part of the mix. This brings to mind the phrase used by Secretary Hillary Clinton, that “it takes a village”. I believe that to succeed in anything, it takes the whole society to come together.
Sunfu: Cancer is such a big disease, so much funding is devoted to it. Yet there is no cure for it.
I agree, for most stage IV cancer there is none yet. But for earlier stages of cancer, statistics all point to our improving the rate of cure and survival. Some cancers are in fact easily treated, and yet there are some that still baffle modern medicine. Cancer is indeed heterogeneous. We are continually trying to fully understand tumor biology which determines the aggressiveness of a particular cancer. We are certainly moving forward, but we are not yet there.
Sunfu: If there is something you can change in the Philippine health care system,what will it be?
I believe there should be a better understanding of health care delivery from the point of view of limited resources and priorities. There seems to be a misalignment sometimes. For example, the DOH thru Philhealth and PCSO provides free medicines and funding for breast cancer chemotherapy,but not the same for surgery when in fact, the primary cure for breastcancer is surgery. So why is that not getting the support it should? Of course there is also not enough effort and resources in prevention, but that is a whole different area. We may need more technocrats rather than politicians in healthcare, or at least better policy makers with proper mindsets and correct motivations.
Sunfu: If you were not in medicine, where would you be?
I actually don’t know. I can’t imagine not being a medical doctor. I am not an arts person. So I may have ended up in something to do with math, life sciences, business or maybe engineering.
Sunfu: There is a lot of attention given to alternative medicine?
Yes, and that is so sad. We have always tried to educate people about the fallacies and myths of alternative medicine, and the overwhelming advantages of evidence-based medicine. Many practitioners of alternative medicine do not have a license to lose like medical doctors, and they do not have to publish their claims in peer-reviewed journals. It seems to be an easy way to make money. They are unfortunately more easily accepted by patients who can be frustrated over standard treatments and also because they are not required by law to inform the patient of the non-benefits of supplements and side effects of their claims. It is sad since there is a notion that they can do something when in fact patients’ desperation is taken advantage of.
Sunfu: There are so-called cancer centers in China that sell themselves as having the cure for cancer. What do you think of them?
That’s another problem. They are draining the already meager resources of those in our country, but they are really not offering anything truly proven to be any more effective than standard treatment. What they are claiming to be new such as cryotherapy for metastatic cancer, has actually been studied for years and disproven. If you go by the evidence, we can be sure they do not help the patient in any unique way that we cannot offer here. If they have developed something truly worthy, they should share it to the major centers in their country and centers of medicine around the world, to save more lives. Sell it at a price even, as most new discoveries are. But they are not doing that. Instead, they are making misleading claims and selling false hopes. We can do that too, except we are bound by the ethics of the profession and respect for human dignity. In the long run, they also damage the Philippine health care industry by depriving us of our resources that should have stayed in the country towards industry viability, which would not be so bad if what they were selling were classified as either experimental, non-standard or outright fantasy.
Sunfu: We don’t have a chance with medical tourism?
I don’t think we have yet the right attitude for this. We have the people and the know-how. But we don’t have the infrastructure of the Thais and the Malaysians or of say a Dubai Healthcare City, which by the name alone tells you it is massive. Or a Mayo Clinic in Rochester, Minnesota, which is over an hour’s drive from the metropolis, yet can attract talent and become one of the best hospitals in the world. So how is it done? By the government providing the right framework and policies and investing in resources to make talent to want to go to them, and stay with them. There is an over-reliance on the private sector to promote medical tourism when this is more of a government initiative. If say, one of the big casinos here near the airport can be converted to a health tourism hub, imagine the boost. Unfortunately, it is not yet in our sphere of the possible in the minds of our authorities.
Sunfu: Any books you have read that you would like to share with our readers.
I think being in the medical profession inevitably gets you an overload of reading journals and medical books just to keep up to date. So, I cannot be naturally averse to reading, but with the nature of my work and time I don’t own much, I may be more of a video and news magazine-type of person. I enjoyed The Emperor of All Maladies by Siddhartha Mukerjee as it goes through the history of cancer and its treatment from which I have gathered viewpoints helpful in my practice. I appreciate the writings of Malcolm Gladwell like Blink and Tipping Point and the novels of Dan Brown till the Lost Symbol, but missed reading Inferno, but will definitely watch the film version. Biographies such as Steve Jobs by Walter Isaacson I also liked, as it revealed how an out-of-the-box thinker can change the world, although you also read about his mistake in going into alternative medicine to beat cancer. He deserved better, as he could have been cured through early surgery and still be alive now. And to share with your readers his controversial yet eloquent last words about books, surgery, the insignificance of the pursuit of wealth and what matters most in life,“…When a person goes into the operating room, he will realize that there is one book that he has yet to finish reading – (the) Book of Healthy Life.. (so) treasure love for your family, love for your spouse, love for your friends. Treatyourself well. Cherish others…”
Our goal is not to be the most creative agency, because that is a subjective thing, and my ego would like to think we are creative. I want us to be the smartest, and data helps us become smarter, and in turn that helps us become more creative, and data because it is tangible is important.
Arturo Dela Pena, MD is the Medical Director of St. Luke’s Global City. He is a man of many hats, being an active surgeon, administrator, academic, and educator. Contrary to the serious demeanor, it always does not take long for him to crack a joke. Yet, underneath the good humor, the man is complex in a positive and interesting way: you enter his room and on his table is a Michael Cacnio sculpture of an anonymous every day man kneeling and kissing the ground to give respect to a crown of thorns. He has Ricardo Semblar’s book Maverick, which is on the radical transformation of a company in Brazil, also on his table, and this is for Dela Pena the management man. Yet under the book is The Teaching of Buddha, and only a pile of papers separate Facility Management and Safety Manual and the book Moments with God, together with the latest bulletin and journals of his medical specialty. This self-professed fan of Rod Stewart and the Beatles is deadly serious when talking about medicine and St. Luke’s Global City.
You wear many hats: educator, administrator, surgeon, academic. Which one is the more prominent one right now?
The answer of course is administration takes up most of my time, and as a consequence I have to cut down on my clinical practice, yet I cannot say it is less prominent in my life, because I give the same time to each of the patient, and without a clinical practice, I will not be in touch with the patient, which is important to my work as an administrator, and without my role as an educator in PGH, I will not be up-to-date not only with what is happening in my field, which is rapidly changing, but I will also not be up-to-date as to the kind of residents and training they are getting . The explosion of data is just incredible, and if you are teaching in front of these young people, you just have to digest the data in a way that you are unlikely to do unless you are there in front of them. All these hats are important, and I cannot say one is less over the other, as administration must constantly be informed by all these.
Yet in research, which is very important, and I am involved with the team of Dr. Adriano Laudico, I cannot say my involvement now is significant, unfortunately. But let me say Dr. Laudico and his team are doing good and significant research on the relation of female hormones to breast cancer. That is the advantage of the younger generation physicians is their training recognizes the importance of this integration of the many aspects that make a good physician. Their academic subjects even in freshman medicine are already being connected to the clinical practice. I have a daughter in 2nd year medicine, so I can see the difference.
What do you tell your daughter who is a doctor? What is the most important thing that you tell your residents that will make them good doctors?
I tell them to learn from the patient: see the patient for what is actually there. Do not just have preconceived notions of what should be or what is said in the book. This is what distinguishes a good clinician from the rest. My father is a farmer, and it is my great misfortune that I did not keep the brown bags he was sending me with his notations about his referrals. He would write in Filipino, for example, “Arturo, apologies, but this patient is asking for help. Please help and see what you can do, as she is complaining about excessive bleeding.” Later on he will ask me what was wrong with the patient, and I will say it was ectopic pregnancy. After many people have come to me through him with his brown paper bag notations, his notation would suddenly say: “This patient is having problem with excessive bleeding, please see if she needs a D & C immediately.” For some patients, later, he will have a note like; “Please see if this is appendix, and it might explode soon.” So I keep telling young doctors, keep examining patients, no matter even if you think it is a simple case of pneumonia, because the more patterns you see, the better off you are in seeing patterns, and yet you also learn that solely relying on patterns is not good, as you also learn that each patient is unique.
How did a son of a farmer become the Medical Director of St. Luke’s Global City, become a leading educator and surgeon?
You know, I recall it now and I still get goose bumps. I remember helping my father in getting copra in Talisay, Batangas, when I was a boy and I tripped: I literally found myself falling face down on horse manure. I remember the anger I had because my father could not stop laughing at me. I was so angry and crying, I said he should not laugh at me. My father said, and I still remember this very clearly, when he said: “Arturo, if you do not study hard, you will just be like me and you will have to work with manure. If you do not want to be like me, only by doing well in school can you become different from me. Or else you will be like me, and your son will be like you.” You know, that turned my life around, and I am convinced, if my father had the privilege of having studied all the way in school, he would have been a great intellectual.
Thankfully you were still able to study in FEU for medicine. How were you able to afford it?
I got to use the education benefits that my father had because he was a guerrilla during the war. My father had a town mate who was the college secretary of FEU and so we decided I should go there. The youngest sister of my father also married a lawyer, and they helped and housed me. They were my parents here in Manila.
What is exciting you in the medical profession right now?
Everything excites me. The opportunities in medicine right now are quantitatively and qualitatively very different from when I was a young surgeon. We are now in a position to improve patient care.
So this is the about the generational change in leadership?
Yes and no. Yes, Dr. Edgardo Cortez our President and CEO is a real visionary. He is really implementing brave and innovative changes in the hospital. But aside from the generational shift, there is more competition, so everybody has to shape up, at the same time there is more data available, so there are real metrics from which you could measure the performance of an organization. This is all changing medicine and hospital administration in the country, all to the betterment of the patient.
Yet it is not just the generation shift in leadership that excites me. The developments in medicine, the speed at which we are beginning to understand diseases, it is astounding. The time may really come when we can predict diseases in a person long before any manifestation is apparent.
There are those who are saying, the competition, due to the entry of conglomerates in the hospital business, are also escalating prices for the patients. What do you think?
Yes, that is true, they are escalating their prices, because they are in health care for profit. That is fine, but also, because you want them to put money in health care to improve health care. Yet we also realize, doctors’ owned hospitals, non-profits, religious-owned hospitals, public hospitals, they also provide another vision of health care, not just the bottom line and excellent service, and I am proud and happy with St. Luke’s Global in that our vision is not just profit, although I have to say, any hospital that is not profitable, except for a government hospital, is not sustainable as the expenses are big and constant. Doctors have, I would like to believe, a different take on running a hospital, compared to, for example, a finance man, or a banker. We have I think over a thousand nurses here in St. Luke’s Global, because we have to allocate a certain number for many departments and functions for three shifts, and you also have to have a backup for the holidays and leaves that are part of the package for employment in a hospital. If you are not profitable as a hospital, it will not take long for you to close down. To say we give the highest standard of care is very easy to say, but many ingredients come into play when you want that to be a reality, from doctors, to geographic location, to the culture of the country. Finance is a big part of that mix as well, we have to admit.
Speaking of location, how are we compared to for example the United States in terms of health care?
Well, it is the most expensive health care system, and we should have learned by now that expensive doesn’t necessarily equate to quality, especially in relation to health care. It is not a question of money for me, because even if you have all the money in the world, are you using it efficiently, wisely, and logically? Because of defensive medicine in the United States, where they ask you to take a battery of test just to protect themselves from lawsuits, when in actuality you do not need the test, it is not necessarily good for you, never mind the waste in your finances. You requests these test for academic reasons? Yes, if there is a reason, but academic reason is vague and has been a blanket rational to just getting the patient to go through all the diagnostic equipment available and I don’t agree with that.
Now going back to your question about going to the United States for your health care; unfortunately health care is not like building a bridge where engineering can compute for you up to the last bag of cement that will be used. The hospital you can standardize the process, the physicians let us say we can even standardize the quality, but the patient, each patient is different from another, and how that disease will develop or evolve you cannot predict with standardization. Maybe you can predict 85 percent of the patients, but how will you know your patient is the 85 percent? For example, you can operate on a patient for breast cancer, and in your research you can do comparisons based on age, economic standing, and yet not all of them will fall into the data; yet your patient is not only not a statistic, but you don’t know which part of the statistic she falls into. Of course if the statistic says the survival rate is this, it doesn’t also mean you will die of cancer. You may die of something earlier or later for a reason totally not related to cancer that you have, so I will study the data, but I will be careful in extrapolating conclusions from the data.
The simple standard should be: there should be the same standard care you get, in the best hospitals in the United States and in the best hospitals in the Philippines, except their culture is very different from our culture. For example, in many clinics or doctor offices, you cannot just show up without an appointment. For example, our hospitals are adjusted to our culture in accommodating watchers or relatives staying overnight with the patient. In many private hospitals, we have the facilities, up to a common pantry that watchers or relatives find useful.
No doubt the United States has one of the most cost ineffective systems of health care, but with the case-rate payment scheme, it is shifting to an opposite extreme in reaction to the excesses of the past, and this has an impact on the decisions of many medical doctors. The most important is what is necessary for you to get well, and I am worried doctors may begin deciding on what is only possible based on your case rate.
Steve Jobs: did his wealth and access to the cutting –edge treatments extend his life?
Maybe. But I really don’t know the specific treatment. Difficult to answer: what measurements do you use as to the reactions of his immune system to the disease or the drugs? How can you quantify this? I know it is not a simple adenocarcinoma of the pancreas, it might be some slow acting tumor, since a neuroendocrine tumor is slower. Is it secondary to the treatment that he received? We don’t know. There is a lead time bias that is important. The latest issue of Time magazine , there is a mention about ductal carcinoma in situ ( DCIS )where it used to be treated with radiation and a removal of the breast, now no treatment is being advised, because it is now seen to be only a premalignant lesion. The disease process now is better understood, and that is also what I meant earlier that the opportunities in understanding of diseases are simply different now, and as a result better treatments are also improving rapidly.
What have you realized now as an administrator you did not know as a doctor?
When you are not part of administration, sometimes you just think of your needs, so you request for the best and latest and most branded equipment, not realizing the fact that the hospital has to spread out its income to many other needs and expenses. Running operations means more than just toys for doctors. Running a hospital also means running things efficiently and as economically as possible without compromising on the patient’s health. And this again is where metrics for service, finance, treatment outcomes all come into play.
Are you saying we have the data?
We will get there. The CEO of St. Luke’s, Dr. Cortez, made a decision of acquiring a data gathering system that will put the data in our hands. We have been going around the world looking for the best system, and we are beginning to narrow it down to only a few vendors. Of course having the best and most accurate data gathering software doesn’t mean anything if it’s too complex or tedious, then we won’t get the cooperation of doctors and nurses, and the whole thing becomes useless. We already tried to do it ourselves and to develop our operating systems, but you realize, the best hospitals and system developers took 20 or 30 years to finally get it right, so you go out and try to find a well-developed system that you can purchase.
Who are the most influential doctors in your career?
Dr. Antonio Limson and Dr. Adriano Laudico, who I always call the best chairman we never had. He was a visionary, like Dr. Limson. They had the vision to develop sub specializations in our field. They sent me to Toranomon Hospital for further studies. Of course in a way I have the best of both worlds, because PGH has the research and training, but there are limitations as well; and the opposite is what we have here in St. Luke’s, which has the private sector need for optimum efficiency, speed, and cutting-edge equipment.
Maybe this is changing? PGH has a big budget for equipment purchases.
I am not sure if a big budget necessarily equates with using your budget efficiently. In the area of purchasing for example, usually government hospitals allocate funds on the basis of democracy, when the more efficient way really is to define your strategic objective as an organization, have the whole organization buy into the vision of the leadership, and the purchases will be based on that strategic objective. I am not sure if you can run PGH on the basis of getting a wide consensus as to strategic objectives. This is not about democracy. Before you can do all that, you have to know your core competence, and you must know where you want to distinguish yourself as an organization. Strategic intent is the most basic for management to decide on purchases. But no doubt PGH has a very strong faculty.
I guess the next question will have to be what distinguishes St. Luke’s from the rest?
The leadership. The President and CEO here, Dr. Cortez, is a real innovator, and his direction is towards building a culture where people can be creative in solving problems. We have invested, through his efforts, on something that changes the treatment and chances of anyone who comes to us with ovarian cancer. Adenocarcinoma of the ovary, for example, we do chemotherapy intraoperatively, heat it up to 42 degrees and we find that the survival rate increases. Many hospitals are looking to wet lab and animal labs, but we went to Israel and bought a simulation system that helps our doctors have more opportunities in training. We are into robotics now as well.
How do you deal with death as a medical doctor?
With the patients, I think it should always be with sincere empathy, and with honesty. I have experienced the loss of my only son when he was only 21 years old, and experiencing something like that changes you in very definite ways: it is never the same anymore after something like that.
It is cruel for a doctor to give people a false sense of hope. It is unethical and immoral. One of my most memorable patients was brought to me by a friend. She comes from one of the rich families in the country. When I saw her, from her workup, I knew she had advanced liver cancer. I gave her the objective clinical diagnosis. She was stunned. She asked for her chances, and I told her the truth that short of a miracle, she did not likely have a lot of time in this world anymore. She thanked me. She said she was wondering why she was not getting well and all doctors were telling her she had this or that, like diagnosing her with hepatitis: nobody wanted to tell her the truth. So, after seeing me, she made her plan to go Lourdes in France, and she asked me for the necessary medical certificates, and she made her pilgrimage, made side trips to relatives living abroad. In fact I remember she asked me what she could get me in her trip to Europe, and I jokingly said one of those famous shirts that has a crocodile as its trademark. That was July. December, on a Friday, on her birthday, she kept calling me because I was the guest of honor for her birthday party, but I was too busy. That was the last time I had talked to her. March she was brought to the hospital for hepatic coma and she died. After two weeks, her two kids came to visit me. They informed I was in her last will and testament: it said that as long as they can afford it, I would get 12 Lacoste shirts every year. I started getting them every December, because she knew December is my birth month, and in fact, I still get them but I had to request, if they insist on giving me the shirts, they do it bi-annually or quarterly, so I don’t end up with the same sets of shirts every year.
Are you religious? You have spiritual books here on your table?
I came from a Catholic family and went to questioning the existence of God and becoming rebellious and wanting immediate social change, and I believe I have come full circle. I have come to believe that when there are no answers to questions, the answers maybe with something higher than us.
What books have you enjoyed that you would like to share with our readers?
Few people can write with social science data like Malcolm Gladwell. I have read Blink, Tipping Point, What the Dog Saw, Outliers. I would encourage people to read him. The very interesting book I always remember is by Captain Michael Abrakoff. His first book is It’s Your Ship, and he relates how he turned one of the worst-ranked US navy ships to become the top ship in the navy in efficiency, cost control, gunnery score in his two years of commanding the ship. It is an amazing book, on how he got feedback from the sailors on how to avoid the rusting of the metal, and he implemented it, and because of that, it meant less time for people devoted to repainting the ship and the time was allocated for some more productive endeavours. It is a simple management book but very good. I am looking forward to this book on my table, Maverick by Ricardo Sembler. It is another leadership book.
Are you a maverick?
No, I don’t think so. I would like to believe my leadership style is to always work within the rules. I think a maverick goes outside the rules. But more than anything, I hope to be remembered as a doer, that I do things that are assigned to me. That I get things done, and not just talk about them.
What is your definition of a good leader?
A good leader must first be a good follower. A good leader must be able to motivate people to get things done and to aim for higher things.