Category Archives: Health Care

The Nobel Prize in Economics 2019: Responsibility Amidst the Chase for Numbers

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.

Former Health Secretary Paulyn Rosell-Ubial, MD (Public Health Advocate)

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.

Interview: Mark Richard Kho, MD (Surgeon, Administrator, Educator)

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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…”

Interview: Arturo Dela Pena, MD (Surgeon, Administrator, Educator, Academic)

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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.

The Sunshine Act

Below is a short brief description of the so-called Sunshine Act, which we got from a website of a pharmaceutical company. We have had several discussions in our company about this, and the issue of payoffs and gifts in the market place. Being in the Philippines and a Filipino company, we are exempted from the Sunshine Act so far. But yesterday, once again, we reminded our team that we are in a special industry, and as a company, we recognize and are reminded of our responsibilities to the many stakeholders of the medical equipment industry. We gave the Sunshine Act some time in our discussions. Our deep commitment to ethics and professionalism continues, and we commit to build on this as part of who we are.

Beginning August 1, 2013, the Physician Payments Sunshine Act (the “Sunshine Act”), which is part of the Affordable Care Act, requires manufacturers of drugs, medical devices, and biologicals that participate in U.S. federal health care programs to track and then report certain payments and items of value given to U.S. physicians and U.S. teaching hospitals (defined as “Covered Recipients”).
The Sunshine Act requires that manufacturers collect this information on a yearly basis and then report it to Centers for Medicare & Medicaid Services (“CMS”) by the 90th day of each subsequent year. On June 30th of each year, CMS will post the reported payments and other transfers of value on its public website. For the initial year of 2013, the collection time period is August 1, 2013 through December 31, 2013, with a reporting deadline of March 31, 2014 (extended to June 30, 2013). CMS has stated it will post the data reported for 2013 on its public website on September 30, 2014.

Vision loss increases risk for thoughts of suicide (From Reuters Health)

Vision loss increases risk for thoughts of suicide
BY SHEREEN LEHMAN
(Reuters Health) – – Vision loss was linked with suicidal thoughts or suicide attempts, in a new study from South Korea.

“People with visual impairment often suffer substantial psychosocial consequences,” the authors wrote in the British Journal of Ophthalmology.

“Ophthalmologists should embrace their responsibility to help reduce suicidality and prevent suicides in patients with low visual acuity by encouraging them to seek psychiatric care, especially in those patients who perceive severe stress because of their ocular disease,” the authors wrote.

The study, by Dr. Tyler Hyungtaek Rim of the Institute of Vision Research at the Yonsei University College of Medicine in Seoul and colleagues, included almost 30,000 adults who underwent eye exams between 2008-2012. Participants also answered questions about their mental health, including suicidal ideation, suicide attempt and depression, as well as whether or not they had sought counseling.

Overall, about 16 percent of participants reported suicidal thoughts during the previous year, and one percent had attempted suicide. Only four percent said a doctor had diagnosed them with depression, however, and only about two percent had received counseling for their mental health issues.

In general, quality of life decreased as vision got worse. In fact, the participants with the poorest vision – profound low vision or no light perception at all – were two times more likely to have had suicidal ideations and three times more likely to have attempted suicide, compared to participants with normal vision.

Dr. Byron Lam, a researcher at the Bascom Palmer Eye Institute at the University of Miami School of Medicine who wasn’t involved in the study, said the study is interesting and the increase in the suicide ideation within the Korean population related to vision is an important finding.

“What’s interesting about their paper is that they didn’t find a connection with depression and we know that vision and visual impairment and depression is very well documented,” Lam said.

Lam said that lack of a finding could be due to differences in the overall prevalence of depression in different ethnic or racial groups, or how depression is assessed.

“I actually thought that finding was a little bit unusual because typically most studies that have been done have found that visual impairment is quite strongly linked to depression,” he said.

Lam has previously compared vision loss to overall death rates, including unintentional deaths and suicide.

“What we do know is that visual impairment definitely increases your risk for mortality, so having poor vision itself already increases your risk for mortality,” Lam said, “Possibly because you can’t perform activities of daily living well and you can’t exercise as much, or maybe it’s harder for you to go to the doctor.”

Lam said the current study adds to the idea that visual impairment doesn’t end with not being able to see, and it actually has many ramifications on a person’s life.

“I think it speaks to the idea that doctors have to be aware, families need to be aware of these implications,” he said.

SOURCE: bmj.co/1EJwsKA British Journal of Ophthalmology, online March 2, 2015.

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.

Start-up Movement for Disaster Relief: or how not to run a disaster operation

EssayA

The photo above does not capture at all the scene in the evening of the 40th day after typhoon Haiyan had hit ground zero. It is a photo, taken from a moving van, of a long road in the still no electric power Tacloban, where thousands of candles were lit up on kilometers of the road to remember the thousands who died during the storm. We don’t want you to think we take this event lightly, as the title of this article may suggest. So what does a start-up movement have to do with disaster and relief operations where so many have died? A lot, if we are to base it on what we have seen in Tacloban, Leyte. Let us begin by tackling multilateral organizations. There is no bigger organization or bureaucracy in the world, probably, than these global humanitarian organizations (Medicin Sans Frontiers, Red Cross, International Organization  of Migration, World Food Program, the United Nations). We can even say these groups have some the strongest brands in the world that will be the envy of equally large,  but for-profit organizations, like Coca Cola. Would you stop in the street to give someone money for whatever charity Coca Cola is working on, or for some product the company is developing? Think of UNICEF or World Vision in contrast.

OLYMPUS DIGITAL CAMERA

We have read so much about the unintended consequences of aid agencies swarming places like Africa; like capturing local talent that eventually joins the aid agencies’ exit of the area. We never expected to experience some of these unintended consequences, and of all places, in the Philippines; not a rich country, but by no means is it wallowing in famine or war. But as soon as our plane landed, we knew it was a different Leyte we would be seeing. In spite of the barrage of television images, and the usual sentimental and caramel-laced ABS-CBN reporting, nothing prepared us for what we saw. From the air and on the ground, we saw dozens and dozens of white tents, army helicopters, fallen trees, and houses and buildings torn to shreds: it was a scene straight out of the movie MASH (about the Korean war), or some B-movie probably entitled “World War III.” This is serious business: and the word “calamity” doesn’t even begin to describe the gravity of what had happened, especially for us who have many friends in Leyte.

EssayC

There are two ideas, or tools, we want multilateral aid agencies to explore: “customer discovery,” which “searches for problem/solutions fit,” and “get out of the building,” which should lead to the concepts about stating your value proposition, pivot, and innovation. (See our previous post on Steve Blank and Saving the World). The people of the Start-up Movement, from Steve Blank to Eric Ries and many others, have taught a lot to entrepreneurs who are inventors, software programmers, businessmen, corporate executives. Non-profits, especially gargantuan organizations like the United Nations, have a lot to learn from the movement. Eric Ries defines a start-up as “an institution, not just a product, and so it requires a new kind of management specifically geared to its context of extreme uncertainty.” There is no more uncertain situation that probably surpasses any business environment of a start-up than a few hours or days after a  cataclysmic disaster hits a locality.

Who are the customers of the United Nations in Leyte? What do they want? We at Sunfu think multilateral relief organizations are overly concentrated on relief operations and their operational/logistics capabilities, as probably perfected in their business plan, but the creation of their business or execution model is largely flawed from the start. For one, the scale of the operations is so big and the resources of the multilateral agencies so  massive, they create problems with their bigness that, having read about these problems over two decades ago, we realized they haven’t learned anything from the criticisms of their host countries that we have read about. For one, almost all the hotels have been commandeered by multilateral agencies, like the United Nations: they just take whole buildings and whole blocks, and in a short-sighted view it looks like they are helping local businesses, but in the end, they are actually hindering it because all of a sudden, the whole island’s operations shift from getting back on their feet mode, its disaster relief mode is prolonged. Now what is wrong with that? A lot.

EssayB

The real customer of these relief organizations is the country. The whole interlocking relations that make the flow of life possible has just stopped. People from outside the island of Leyte, or even just the city of Tacloban, will have a hard time moving in to help or bring back normalcy into the place, to look for family, or to begin looking and connecting for business opportunities, because all of a sudden, there are no accommodations for months, all the restaurants are filled up, and so life is in a stand still because the multilateral organizations have a whole set of checklists they have to fulfill in order to report to headquarters in New York, or Geneva, or Paris that they have done their jobs: the right photo opportunities have to be taken, the right video clips have to be shot, and as Ban Ki-moon appealed for today, more funds would move in to feed this cycle. The infrastructure of the island that survived are being commandeered by the size, good intentions, and wealth of these giant aid agencies, which feeds more the need for relief, and we fear, they will further institutionalize mendicancy. Most hotels, even lousy hotels, have been booked for until June 2014. Do aid agencies know of these consequences? Do they know their customer?

EssayH

Part of the panic, which fed into the looting, was caused by the fear that there would be no food available commercially. Money thus becomes worthless. Yet for us, the Sunfu team, it took us hours to find breakfast, because the available restaurants were filled up with aid workers, some with the insensitive posting on the entrance of an establishment saying this or that restaurant is exclusive for this and that group. The result is some of us had to go out for hours looking for breakfast, losing our patience and temper a few times, because the paratroopers of agencies like the U.N. have not been going out the building, or in this case, their hotels, except to distribute relief, do site  inspections, and prepare for the arrival of agency bigwigs. But the area, the city, or even the whole province will not rise if the ecosystem of the whole province is under the strangle hold of multilateral agencies that want to make sure their tents are up, the food packs readily available, and they have done their mandate. Who can argue with that?  A comment from one of the barangay captains, which I thought worth repeating: “The stores are beginning to open, which is the best sign that things will go back to normal.”  But the aid agencies are hindering the flow of goods as trucks and other kinds of vehicles have been rented out at incredibly high prices. In fact, she said if the looting did not happen, whatever the devastation, people would have been able to pick themselves up faster. The point is get the customers up their feet, and the fastest way is to give them the capacity to get up: if you are in a medical mission, after the mission of a few days, just enough time to give the local doctors to recover, they leave them capacity to do their jobs. But that would be very expensive, and less dramatic. Not much photo opportunity, and fewer occasions to have contact with the media and the general populace. The validation of the customer therefore should not be in that the patient is not dead, or is up and about, but the validation is if their lives have gone back to normal as soon as possible, or is it even better and more productive than before. From our angle, what we see is most multilateral agencies are there to help, but their help ends with the “feeding mission,” or the “medical mission.” Tzu Chi, the Buddhist charity organization, seems to have gotten it right. They immediately did a work for money program: help clean up certain streets of debris and you get money. That helped clear some streets. They also had a medical mission component. Yet they also just distributed money, and we are talking about P10,000 to P20,000 (in US dollar terms it’s somewhere at the minimum of USD200 to USD500). The group gave people capacity and capacity immediately to get some of the resources they knew they needed and wanted, and it gave some life to the local economy. Tzu Chi left immediately afterwards, and its members were not in the way by hogging resources of the place (very Buddhist).

There were sardine cans from charity organization being sold in the market by recipients, hardly any takers, as canned sardines coming from charity organizations flooded the island. Recipients of these sardines were simply sick and tired of sardines, after weeks of nothing but sardines. They want variety, they want to move on, they don’t want the same fare day in and out. Inedible relief food packs have found their way in the market: with hardly any takers. This is not corruption, as some in media have claimed: this is the market somehow throwing out (vomiting) the food it is being fed, trying to monetize the situation in order to get going. One of the biggest hits, and the long lines of people waiting for their turn was the best proof, was when Mayor Sandy Javier’s restaurant, Andok’s Manok, opened: people patiently waited for hours to pay good money to get some juicy roasted chicken. Nothing like good food to heal the body and uplift the spirit. Even we fell in line. No doubt his being mayor of a small Leyte town and he is somehow also related by party affiliation to the province’s governor helped, as government electric generators helped light up the  establishment’s surrounding area. But good food is good food: whatever the criticisms were muted by great hot crispy juicy chicken.

EssayE

We know it sounds callous to be so calculating, at the same time critical of multilateral agencies who certainly want to save lives as well. But the multilateral agencies we observed were actually not looking at capacity building: they were looking to yes saving lives, but they were simply also looking at this as a job, a good job, a serious job, a vocation even. But they were not looking at this as an entrepreneurial enterprise that would fold up if it didn’t succeed in hitting its goals of making the customers happy, or getting the customers’ lives back to normal, immediately. And here is the other suggestion we can take from the start-up movement: verbalize what you or your founders are trying to do. If I am to just cite two perceptive and very interesting articles written about the disasters that have happened to the country, the phrase that stands out is “capacity building.” This is what is needed: capacity building. Very important. Equally important is to ask: But capacity for what? This is not about giving the fisherman boats and nets to fish: it is a lot more than this.

The first article is by Gabriela Luz, who works with Oxfam. She writes in the Philippine Daily Inquirer about what has happened to them in earthquake-struck Bohol, after Haiyan devastated Leyte: “In a natural disaster, the immediate assumption is that the most vulnerable are stripped of basic needs: food, water, shelter. There’s a race against time to deliver aid that would meet the big three. We in humanitarian agencies have been working in emergencies for so long that we’ve broken down aid to food packs, hygiene kits, water kits and emergency shelter.

“What happened in earthquake-struck Bohol was that agencies working on the ground were still trying to meet these needs when Yolanda hit, and then markets instantly dried up. Cebu was the nearest large market and logisticians trying to procure supplies were shut out. Supplies coming into Tagbilaran were suddenly diverted to Cebu hubs because the needs were bigger and more immediate in Yolanda-hit cities with zero systems.

“Granting that you can purchase the right number of aid kits needed, there’s still the problem of getting these in. What happened in Yolanda is that places like Leyte had no local suppliers. There were no vehicles, no fuel, no trucking. Everything had to be sourced from the outside. You’re scrambling to get the next available vehicle—but you’re not the only organization trying to do so. Suddenly, suppliers who could bring relief in were in high demand and could control prices. It was costing up to P10,000 just to rent a vehicle. Trucking companies were canceling arrangements in the middle of the night, right before a distribution, because of higher bids worth more money.

“Hand in hand with resources is the human element. In the humanitarian field, only a relatively small number of people are equipped to work in emergencies. Finding someone to do emergency work means finding a person with the technical expertise, knowledge and experience not just to respond but also to figure out how to go beyond response and move toward recovery as quickly as possible. Immediately after Yolanda, experienced humanitarian workers were being pulled out of Bohol to work where the need was greater.

 

 ”In Bohol, we’re seeing issues crop up again because needs are overlooked. People don’t know how long they will stay in their current living conditions. Livelihoods are still a question mark. As for Zamboanga, people are still in evacuation centers. Incredibly distressing issues on gender-based violence and protection are rising. There are reports of prostitution, involving even children for a tiny bit of money. But even with these issues cropping up, who is left to cover them?

“Recognizing that a competition of emergencies can happen is important because the pressure of it consistently happening should add to how we understand the scale of preparing for disasters. Here are some things we should consider to acknowledge this problem:

“Capacity-building and going local. We know that we are a country overrun by disasters and that it’s going to get worse. And we know we don’t have the personnel to respond to this on our own. We need to spread the knowledge, the capacity, around, so if we ourselves can’t do it, then we know others can.”

It is interesting to read the article because coming from the point of view of someone who works for a giant aid agency, she looks at capacity building as being prepared for disasters. While we advocate for start-up tools, we also advocate capacity building, in allowing the locality to figure out what they need to be strong, not for disasters, but for life, maybe with the help of aid workers getting out of the way after the initial stage of relief: or at the very least, to get out of the relief mode and immediately into capacity building, not for disaster preparedness (as Nassim Taleb would say, there is no way of preparing for Black Swans, but there is a way to be Anti-Fragile), but to be strong and have a mind set of strength by helping provide the mental tools to have the mind set of running their lives, or households, or employment, or companies as start-ups. The whole NGO and multilateral aid agency community must get out of the disaster relief mind-set, and it must get into the entrepreneurial start-up mode.

Here is another article, this time by Art Villasanta and Peter Galace, also published in the Philippine Daily Inquirer just three days after the above article from the Oxfam worker: “Tom van der Heyden, a satellite expert who works in the Philippines, said the country needs to be properly educated to properly appreciate what a satellite can do. He noted that its satellite requirement ‘has always been urgent.’ The Philippines, however, needs to have people in the highest positions who understand what can be done with a satellite.

‘Buying a truck will not help if you have no experience driving a truck. The country needs to build up capabilities, and then a satellite, so that the satellite is not just a drain on the economy but can serve the people and business,’ Heyden said.

“He emphasized that the Philippines also needs a satellite for maritime security and to protect its waters and borders. In this vein, Pimentel said the Philippine military should have quick-deploy VSAT systems and a hub with the necessary IP backhaul connectivity. ‘It is pathetic that today, the VSAT network of the [military] is actually on a Chinese satellite!’

“The Philippines has orbited only two satellites: the derelict Agila-1 and Agila-2, which is now operated by Asia Broadcast Satellite, and serves Africa. ‘Forewarned is forearmed’ is a lesson we should have learned long ago from the unending procession of natural disasters that pummel us without fail every year. We must immediately heed this lesson. Nature is not merciful, and never will be.

“We need a Philippine satellite now to save Filipino lives in the future.”

The excerpt above talks about “build(ing) up capabilities” in the high tech sense of having the technology, in this case a satellite, to withstand another typhoon Haiyan. We think in this blog we are writing, our point about capacity building is clear: we are different from these two articles in that we interpret capacity building eventually as a mind-set first, with approaches to the problem (the start-up movement tools) second, and third, but no less important, an eco-system within the local and national boarders (how unfortunate that we still have to talk about national boarders in the 21st century) that makes it possible for channels of commerce, goods, health care to freely flow and be strong no matter what situation, even after a major disruption by an earthquake (Bohol), invasion of gangsters (Zamboanga), or a typhoon (Leyte). After the initial first week: the relief mentality must immediately shift to local capacity building. In fact, it is a golden moment to get a community to be better than it was before the disaster.

With organizations like the United Nations, the magnitude of their operations and the professionalism involved: you know even if pursued with passion, the organizational momentum is towards feeding and temporarily housing people: these tasks will take up most of the organizational energy. This is partly, but also hardly, capacity building.  Steve Blank is now talking about metrics and software programs that measure indicators of success of a start-up, and that has got us worried. We think that many victories and successes of a start-up, aside from the bottom line, will never be measurable, because a surviving start-up is a confluence of events and initiatives as it looks for a scalable model. The danger, always, for the start-up is that it will not be able to withstand the shocks the competitors, the market, and other Black Swans are throwing at it. The other danger is that it will start looking and believing that what matters are what are measurable, which is a trap of these giant NGOs and aid agencies-mind set. But the reason we are enamored by start-up thinking tools is because we think Steve Blank and the other articulators of this movement are able to find the equipment (or point-of-view) for people, entrepreneurs, to understand and take the shocks, by being lean and agile, by having the correct mental outlook and desire to fail, fail fast, and pivot.

And here is where getting out of the building is important: the concept in the start-up movement is for the founders or entrepreneurs to get out of the building to meet the customer, to develop customers and knowledge of the customers, to see their problems, to find out what they want and what are the solutions. Aid workers will tell you that in fact they are out, seeing the problems, and solving them. But we would argue, the generals of this army, like Ban Ki-moon, and the rest of the team should stay out of hotels and, in the evening, sleep in their tents (literally) during the duration of their stay. They want to spend money, then instead of spending them on hotels, rent out parcels of vacant land for their UN tents for their staff and generals to stay in. Perhaps they will find out why, in spite of so many tents available, people prefer to go back to their destroyed houses. Many tents are actually unoccupied. Other charitable organizations, when out there, will find out that, locals and local government officials do not know what to do with old clothes being sent their way, and if it will not offend, we have no doubt many of them would gladly pour some fuel and throw a lighted match on the clothes. They don’t need them. Those that do, they want new clothes. Local governments are in fix as to what to do with donated used clothes, without appearing ungrateful.

EssayF

Indeed, a provincial administrator of the local government very provocatively asked: why have most parachute doctors and hospitals from donor agencies and countries not visited the local public hospitals and given or helped the local hospitals in having the capacity to do their work, as the local doctors there know the culture and the language of the area? The patients are flocking to these places, only to find devastation. The local doctors are just there, waiting. Some of the most sophisticated medical ships, mobile clinics, military hospitals came over from different countries, mostly from countries that have experienced or are currently experiencing military expansion, thus the development of very mobile medical teams and equipment. But they never gave the local provincial hospitals and doctors capacity: hardly anyone asked how they were doing. Sure a tent or two, with some medical tools were left behind by a group, but it was not even a dot in the ocean of need. The local doctors who know the problems, local language, the patients and their medical history: they were just left to clean up and wait for the national and local government to get their act together and go through the tedious task of meeting stringent purchasing rules to get the necessary equipment to get going. This is not a criticism of the local and national governments, but an acknowledgement again that the bureaucracy has its own rules and momentum, its own checklists of requirements, that dictates its actions and ability. It cannot move unless certain boxes have been checked. It needs a start-up culture, or at least it needs to have start-up clusters and teams. Yet local governments have the edge of having the local knowledge of each area’s idiosyncratic culture, specifics of who is in need, and the location of infrastructure to get whatever needs to be brought to the end-user. It will be difficult, if not impossible, to ignore them. Of course just like the experience of the Red Cross in Bohol in getting into a conflict with a town mayor who wanted to have a say in relief distribution, there is fear of being sucked into the local politics of each locality, thus the desire to avoid local officials. Fine: then get out of the hotel and literally stay in your tents as home and office: live literally on the ground. This way, not only is the feed back loop easier, faster, and more realistic: they do not hamper the normal flow of commerce by hogging all the resources of the locality. If bringing and cooking your own food is a problem, or is simply not the solution, leave half the space of the restaurant for other locals, do-gooders, entrepreneurs, scientists, and aid workers to buy their meal. Of course hospitals getting donated medical equipment will not be good for local businesses like Sunfu, so maybe donating countries can purchase equipment from businesses like us, and if they prefer, they only buy equipment that are manufactured or invented by their countrymen that businesses like us sell, as a sort of compromise (as this seems to be an issue for some); or better, support equipment invented and manufactured by us (although honestly medical equipment manufacturing is still a pipe dream in this country, as there is no capacity: although Sunfu Solutions is trying, and may partner with Dr. Harvey Uy in the future for some initiatives in ophthalmologic solutions).

Yesterday Ban Ki-moon appealed for more funds for food, shelter, water, and health. We could only imagine if this almost $1 billion US dollars of fresh funds could be used to fund an honest-to-goodness start-up movement within the UN for Leyte, and on the ground where their foot soldiers are all out trying to make a difference in the lives of Filipinos. There is a big movement in the Philippines called Go Negosyo, which encourages Filipinos to become entrepreneurs in a culture where dreams are for our loved ones to join the biggest corporations, which can withstand the shocks thrown by life at an individual. Work for a great big company and they have health care, insurance, yearly bonuses, and so on to protect the employee. We have always approached the Go Negosyo program with skepticism because, for one, the underlying current of the initiatives is government cannot help you, and for its failures, you are on your own: so look at these millionaires and billionaires (some of them modern day pirates) and see if you can be like them. The end goal, end philosophy, is to be self-sufficient. In the context of the Philippines, the start-up movement is worth pursuing, as it provides the outlook and tools in working towards self-sufficiency, but it needs to be added, in the context of the Third World, with the consciousness of the need for local capacity building, technology transfer, management innovation, and human capital development. The task and challenges are enormous: the start-up movement just provides conceptual tools to get started, to withstand and understand the shocks, the Black Swans, and if successful, to have the necessary mindset to see the world with eyes of a hungry and innovative entrepreneur.

In the context of the Third World, we know many of these apps and technologies out there, being produced by start-ups in places like Silicon Valley, are just toys; made for the First World, or worse, made for venture capitalists. (See article in  “Can Silicon Valley Save the World?” by Charles Kenny and Justin Sandefur in Foreign Policy, July/August 2013, about innovation in the devices and gadgets supposed to help the Third World defeat poverty that are impractical if not laughable: example, a solar powered soccer ball that generates power when rolled, but cost maybe 10 times more than more practical and less sexy gadgets. Cute, but no thanks). We need local capacity-building start-ups, not band-aid solutions, we need start-ups that have a culture that will save lives beyond mendicancy, and on the other extreme, start-ups must also look beyond just the bottom line and the great global technology fetish. We do not need start-ups like a new gasoline station company in the Philippines which declared that it is decorating and lighting their gasoline stations like First World gasoline stations. Shell and Petron have done that years ago in the Philippines. Their other stated goal is to franchise out as many gasoline stations as the wildly successful Jollibee Hamburger. That’s innovation?

One of the most precious commodities for days, after typhoon Haiyan hit Leyte, more precious  than gold, were to have liters of gasoline to run vehicles. People fell in line for over a full day to get their share, and only the opening up of alternatives like in the photo below alleviated the pressure on the community, which served to dissipate the panic. The black market helped calm down the communities, because money, the traditional medium of exchange and value, is back in circulation. How can gasoline stations service small entrepreneurs in the photo below, without being a danger the environment (using water and soda bottles as gasoline containers!), and skyrocketing prices?  The need for goods to be readily available, not be hogged by a select few (no matter how good their intentions), they need to have a mind set to state the hypothesis or goal, to know the customer and have the hypothesis validated, and to literally get out of the building (and for multilateral aid agencies to live outside the hotel buildings) are necessary: we need a start-up culture obviously, yes, and we also need a start-up set of tools, sure; but equally necessary, we should not be too target driven when we enter a business or a relief operation, because we should be looking, with a clear and hard eye, at what the customer wants and needs. We cannot enter a situation with our preconceived notions. One of the great ideas articulated by Steve Blank is that no business plan ever survives first contact with the customer. Think about that. Why is that so true United Nations?

Essay

 

Interview: Jay Famador, MD (Ob-Gyn and Gynecologic Oncologist)

Jay Arnold Famador, MD

Jay Arnold Famador, MD

Our interview with Dr. Samuel Ang received an incredible number of hits, and the positive feedback from our readers have exceeded even our most optimistic expectations. Aside from Dr. Ang’s large following, we thought this may be due to the great interest worldwide on cancer, and so this time we decided to interview Dr. Jay Arnold Famador, a fast rising Filipino gynecologic oncologist, also known for his compassion for the patient, to get a perspective from a more junior member of the medical community. Dr. Famador was a student council president in his college-activist days at the Ateneo De Manila University, earning an undergraduate degree in economics, and soon after graduation served in Butuan, Agusan Del Sur, as an economics teacher. He came back to Manila and soon entered medical school. He is now an obstetric gynecologist and gynecologic oncologist. We are certain to hear more good things about him from the medical community in the near future. Here are excerpts of our interview conducted via email while Dr. Famador was in Vietnam:

What is getting you excited about your profession?

Radical tumor debulking cancer surgery (cytoreductive surgery) and minimally invasive surgery (laparoscopic surgery) have been quite exciting for me.

Kindly elaborate on this for the lay person.

These are surgical techniques that I have been learning recently and slowly adopting in the treatment of my patients.

Cytoreductive surgery aims to remove all visible tumors in the abdominal cavity.  In the surgical treatment of advanced ovarian cancer, usually we have to be content with removing minimal amount of tumor just to make a biopsy because of the extensive spread of the cancer all over the abdomen. We then hope that chemotherapy will be able slow down the disease to allow for some extension of life. The techniques we are learning now will hopefully allow us to go after tumors that have spread, which we used to just leave behind.

Laparoscopy or minimally invasive surgery isn’t really new. It’s just new to me. The excitement derives from the learning, in improving one’s craft, and the practical benefits these may have for patients.

Why are you in Vietnam? What is unique about them?

Last month, I was with seven other Filipino doctors attended a workshop on cytoreductive surgery for ovarian cancer in the University of California Irvine. The workshop exposed us to cutting-edge surgical techniques and I hope that this learning opportunity will translate into better treatment outcomes for our patients back home.

Currently, I am back in Vietnam with a couple of colleagues continuing a training course in gynecologic laparoscopic surgery. Although training in laparoscopy is now being offered in Manila by our own local experts in an effort to pass on their knowledge and skills to fellow Filipino colleagues, the economics involved for interested individuals is still quite prohibitive. Our Vietnamese counterparts were offering a training course that was relatively much cheaper compared to ours as well as to those in other countries, the venue was geographically feasible, and indeed it was a chance to be exposed to technology that is already standard of care internationally.

What immediately struck me was that the gynecologic surgeries here are routinely done laparoscopically unless medically contraindicated. Back in the Philippines, laparoscopic surgery is reserved only for those who can afford it. In Vietnam or at least in this particular government hospital, it is the standard of care for all patients.

According to one of the doctors I asked, their “normal” patients (as opposed to private patients), would spend only around 100-200 US dollars for laparoscopic surgery in their hospital. That their government has been able to keep these costs low to benefit the people is extremely impressive to me.

How many years have you been practicing? And after all these years, what have you learned about us human beings in the practice of your profession?

I have only been in private practice for around five years. I have seen and accepted that mankind struggles endlessly in various levels and spheres of existence to overcome conflict. Some conflicts are due to “acts of God,” like cancer in the case of my patients, or Yolanda in the case of recent typhoon victims. A lot of conflicts however, whether individual or societal, I think, are also self-inflicted, caused by irrational choices, emotional instability, ignorance, or even outright psychiatric pathology.

What is the most frustrating part of your job?

What can really be frustrating is when my ability to treat a patient is limited by economic realities.

If there is something you can improve with the health care system of the Philippines, what would it be?

Number one would be to rationalize the access of indigent patients to government subsidies for public healthcare services. Patients seeking government funding for treatment have to go all the way to legislators or the Philippine Charity Sweepstakes to line up and wait for a month or more to obtain some letter of authority to present to a hospital like the Philippine General Hospital to allow the release of a meager amount. There must be a more efficient way of doing this.

How did your undergraduate years as an economics student at the Ateneo de Manila University help you as a medical doctor?

I’m not really sure, but I think being a student of economics during my undergraduate years allowed me to gain a broader perspective of the world. Unless one is in the field of public health or maybe epidemiology, the practice of specialized medicine tends to narrow one’s perspective of reality. I guess the little exposure I got in earning my undergraduate degree in economics helped me gain a more multidimensional appreciation of the world.

If you could do it all over again, would you have gone straight to pre-med, or would you still have opted for the route of going for an undergraduate degree in economics?

If I had a choice, I would still prefer the route I took.

Studying medicine mostly involves years of memorizing volumes of information and constantly preparing to be tested on how much you can recall. It kills the brain. It is intellectual torture. Intellectual curiosity and critical thought can easily be stifled over the years of driving oneself to become a doctor. Contrary to the image that studying medicine to become a doctor will make you smarter; it can actually make you dumb, or dumber.

Who influenced you the most in your formation as a medical doctor?

It would have to be my father, Dr. Benjamin Famador, Jr. who happens to also be a fellow obstetrician-gynecologist and gynecologic oncologist. My mother is a pediatrician so both my parents are doctors. During my residency training, I had the privilege to observe my father practice and to directly learn from him. His skill as a gynecologic surgeon is difficult to equal. He is an idealist who has preached and practiced ethical medicine: sometimes too dogmatically to a fault. He told me not to be content with my training as a resident and urged me to seek further subspecialty training even if it entailed additional years of sacrifice.

Please share some books or authors that have helped you and you want our readers to know about.

Most of the reading I have been doing have been limited to medical journals. Not much excitement there but a necessity to keep abreast with my field of specialization. Surgery for Ovarian Cancer by Robert Bristow and Beth Karlan is the latest medical book I got. The one and only non-medical book I read recently is Philippine Cultural Disasters: Essays on an Age of Hyper Consumption by my good friend R. Kwan Laurel.  I really have to acknowledge my friend because the only authors whom I would say have helped me understand the world were those handful of thinkers I had the good fortune of reading because of him: Erich Fromm, Herbert Marcuse, Edward Said. But those readings were long ago. They were read during my university days. Having the time to read at leisure is something I greatly miss and is a privilege I no longer have.

 

Interview: Samuel Ang, MD (Surgeon and Surgical Oncologist)

Dr. Samuel Ang from the Tzu Chi website

Dr. Samuel Ang from the Tzu Chi website

Samuel D. Ang is a top general surgeon and surgical oncologist in the Philippines. What is amazing in observing his practice is not the overflow of patients in the waiting room, but the diversity of patients, representing various sections of the Philippine economic pyramid.

Sunfu: Thank you for allowing us to have you as our first medical doctor to appear in our blog. Dr. Ang how long have you been practicing medicine?

Dr. Ang: I have been practicing for 30 years already.

Sunfu: What surprises you still about medicine?

Dr. Ang: The truth is I am surprised by how insignificant we are as doctors to saving a life. Sometimes you have done your best, you think you have been instrumental in curing a patient, and then you find out, you did not cure the patient after all. The older I get, the more I feel there is a greater Being, and I am humbled by this experience.

Sunfu: Are you saying your profession has made you more religious?

Dr. Ang: Yes, definitely. I can give you an example: I have two 90-year-old patients right now. The surgical operation I had with them is actually very simple. But I know for 90-year-old bodies, with all the technology and advances in science, so many things can go wrong. As a doctor, I am not so egotistical as when I was young when I thought the doctor could do this without anything going wrong. At the same time, I am also not so hard on myself when something does go wrong. Before, if something goes wrong, I blame myself. Now, I just do my best, but God takes care of the rest. When people congratulate me that I am so good for supposedly curing a patient, it doesn’t affect me. I know where I stand in the scheme of things. I am just an instrument.

Sunfu: What is the state of the Philippine health care capability in terms of cancer? People want to go to the United States, saying the protocols there will be different, in fact superior.

Dr. Ang: I think Filipino patients who go to the US have a shift in perspective when they go to the US. In the US, there is a more impersonal care, and the patient usually is not able to negotiate with the doctor. So in a sense, the expectation is also heightened because some believe the quality of care will be better. I happen to disagree. Of course the amounts of money spent when in the US are staggering, so there is also a tendency to want to justify, or to rationalize, the expense.

Sunfu: But wouldn’t they have better machines?

Dr. Ang: Yes, no question about it. If you are talking about radiologic oncology, yes. But if you are talking about chemo therapy or surgery, I don’t think there is a difference. They have the money to invest on very expensive machines because their patients can pay for them. We hardly have any users among our patients for these very high-end machines because Filipinos cannot afford them. Yet for those who can afford, many go to the United States directly, so hospitals here do not want to invest in them. We are talking about, in US dollar terms, a difference of going through machine diagnosis and paying $40,0000 versus going for the same machine diagnosis here and paying only $2,000. The insurance takes care of it there in the United States. The US hospitals have the money to invest in the latest and most expensive machines. In molecular pathology, we are definitely behind. A genetic test will cost around $5000 US dollars. How many people can afford that here? Not many. There is also an advantage, maybe, of going to places like Harvard, where they are doing clinical trials on the latest drugs.

For the usual cancer, the more common cancer, I have no doubt our quality of care is equal the US and Europe.

Sunfu: What are your criteria for you to call someone a good doctor?

Dr. Ang: First, compassion is the most important for me. The desire to learn new things is also important, because if you stand still, you are already behind, especially in oncology. The progress is simply too fast. Pacifico Yap is a great doctor who I admire because he is already in his eighties in age, yet he is still studying and trying to learn.

What I don’t like is doctors who complain because, for example, a phone call from a patient is a nuisance for them. For me if you don’t have that compassion, if you don’t enjoy seeing patients, you should not have gone into medicine in the first place. A great majority of people go into medicine because they want to serve and they have good hearts, so it is rare to find a doctor who doesn’t like seeing patients.

Medicine is a vocation. If you don’t enjoy it, get out.

Sunfu: How about doctor-teachers, who have been important to you?

Dr. Ang: Dr. Abes, Cresensio Abes is a great surgeon. I admire him. Dr. Augusto Sarmiento I admire for his very sharp mind. Dr. Ernesto Domingo was never my teacher, but I have great admiration for him. Of course in the category of friends, Dr. Patricia Tan and Dr. Fernando Chua, they are friends but I also admire them. Dr. Conrado Cajucom, among the young guys, I admire. I admire all these young bright minds, these high IQ people. Maybe because I consider myself a regular guy who has to work doubly hard, when I meet bright people like my classmate Dr. Richard Yap, I admire them.

Sunfu: What excites you about your field today?

Dr. Ang: Oncology? A lot. I think Atul Gawande is correct: the surgeon as God, as superstar, as hero, that time is over. Teamwork excites me. Team work is the best. You cannot carry the burden of the world. When I was a student, the surgeon is the only guy who mattered in the surgery room. From the macro part, radiation oncology, the surgeons, to the micro part, the development of the patient, they all excite me. In the early days, the concentration was simply the disease, but now it is more than that. This is the reason why alternative medicine became too popular, and Steve Jobs is a good example, a bright guy who thought fruits and vegetables and lifestyle changes would cure him of cancer. Before we just took out the tumor and passed the patient to chemo, and if the patient was not killed by chemo, he went to radiology that would have burned him. Many doctors then were not compassionate, but were too disease centered, and their actions pushed the popularity of alternative medicine to the detriment of the patient.

Sunfu: You have four kids and all of them are now doctors. What do you tell them?

Dr. Ang: I tell them they do not have to be very bright, but as doctors, they have to have the heart, the heart to help people. Money is not the priority if you are a doctor. Or else, you will just be frustrated.

Sunfu: Where did you get this sense of compassion?

Dr. Ang: I guess my mother. I come from a poor family, a very poor family, but money was never a subject of discussion. We had a small sari-sari store in Davao City, and our relatives from the outskirts of Davao, we open our doors to them and we always had guests, and we cook for them and we welcome them. My mother was very hard working, and my parents were willing to always share what they had. I guess I got it from that upbringing, from that very open environment.

Sunfu: I know you are a big reader of books. Please give us a few names of authors you would like to share to our readers.

Dr. Ang: Atul Gawande’s Checklist Manifesto and his book Complications. Siddhartha Mukherjee’s Emperor of Maladies is a beautiful book, a book on the history of cancer. Eugene O’Kelly’s Chasing Daylight: How My Forthcoming Death Transformed My Life. This is a book about a former KPMG CEO who was about to die. Fiction I really liked Jhumpa Lahiri’s Namesake.