Category Archives: Interview

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)

mark-richard-kho11

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)

DelaPena

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.

Interview: Manuel Chua Chiaco, Jr., MD (Cardiovascular Surgeon, Educator, Administrator)

Chua

We were looking for Dr. Manuel Chua Chiaco, Jr. in the whole Philippine Heart Center complex while he was doing his rounds, and immediately we recognized him by the way the security guard saluted as he exited one of the buildings. One knows nobody gets that kind of a sharp salute in a government institution unless one is the President of the Republic, or the executive director of that particular institution. Before I get to him, he catches one of the young consultants and told him: “We have some doctors from the provinces coming. My only request is whatever you think of them, you teach them, you give them the best of what you know. That is my only request that you guys do while I am director of this hospital.” Then, finally, we got his attention. We explained our purpose there, and asked if it’s possible to get an appointment. He agreed. But it took weeks trying to set up an appointment. There was a back and forth between us and his secretary. And we never really succeeded until we just walked in one day with a formal letter for an invitation for this interview, and he had the time, but not until he finished his conversation on the phone, informing somebody that, if this patient based in the Visayas would be charged P2MM as a private patient in a provincial private hospital, and P1MM in a public hospital, then the patient could come to the Heart Center, or better yet Dr. Chua Chiaco is willing to get himself on the plane and fly to the province, at less than 1/3 the price of what the patient was being charged in the best public and private hospitals in the Visayas.

Sunfu: What is exciting you in your field right now?

That we are bring Heart Center quality cardiology in the far flung provinces is what excites me right now. People in the rural areas cannot get the care they need there, and they have to come to Manila. . A governor told me they have a P200 million hospital, but no doctors. They have the structures, but they don’t have anyone to man them. We have identified places where we can put our efforts, and we have started with Cagayan de Oro. We talked to the director of the Northern Mindanao Medical Center. We told him: give us doctors, we will train them, so long as they go back and practice in Cagayan de Oro. We have finished training two cardiologists, three cardiac surgeons, two anesthesiologists have gone back trained in cardiac anesthesia. So by the middle of this year, you have a complete complement of doctors that can give the same quality of care you can get here at the Heart Center.

Sunfu: Isn’t that too grand a claim? Equal the quality of care of the Philippine Heart Center?

No. Our idea with former health secretary Dr. Enrique Ona is to build regional heart centers all over the country. We are going to the extent of naming this place in Cagayan de Oro as the Philippine Heart Center of Northern Mindanao. There is a branding there. We are ready to stake a claim that they are going to receive the same kind of care that they will get if they go to the Philippine Heart Center in Manila.

Sunfu: Is there an assumption that medical training of our doctors is even, regardless of location?

No, there is no evenness. Granted there are bad medical schools. No way can a medical school do well when you only have three students for the whole medical school. We also have too many schools. But we should also not abandon them and say they are not trainable: it just doesn’t follow. In fact, the farther they are from Manila, the higher priority they should get in training in the Heart Center.

A lot of our educators cannot get rid of the notion that they will only train the smartest. I don’t believe in that. I believe we need specialists and we need a lot of specialists outside Metro Manila, regardless of how they started their medical education. Being the smartest is not enough, or sometimes it doesn’t even mean anything. We can train them to be good and effective cardiologists is enough; they don’t have to be the best. But also, please, don’t think they have no chance of becoming the best.

Sunfu: Any other qualifications aside from geographical distance?

At this time, geographic distance from Metro Manila is our priority. We have Philhealth, but we don’t have the doctors out there for the marginalized; so there is no access to facilities, qualified doctors, and the right equipment; if so, in that particular area, Philhealth doesn’t mean anything.

Sunfu: How about the elite in these far flung areas? They will still come to Manila?

Yes, but the goal is for them to be confident enough that even they don’t have to come to Manila.

Many good surgeons in the country have trained in the Heart Center, and regardless of where you come from, we give you the same training. I am confident those we have trained will get more and more proficient as they go along. But of course there will be disappointments. There are those who are bright and have what you think are qualities of becoming a great surgeon, but it doesn’t happen all the time and you can’t explain it. That is part of being an educator. Davao already has a very good cardiac group there, and Cebu has a thriving cardiology community: these are Heart Center-trained doctors. The people there or near there, they don’t have to go to Manila or abroad for any heart procedure or diagnosis.

Sunfu: But you still mention centers of commerce: Davao and Cebu. Not yet Tawi-Tawi, Basilan, Samar.

That is where we need government support. Cardiac diseases are very expensive to diagnose and to treat. It requires a lot of training, extensive training, and it requires expensive equipment, not only to buy the equipment, but to maintain these equipment: sometimes it is more expensive to maintain them than to buy them.

Sunfu: This is where you may part ways with some of our friends in public health advocacies. They will ask why they should support you when there are areas in the Philippines where schistosomiasis is still a reality.

This is where the whole reality of the problem in the Philippines comes in. We cannot ignore that what you are saying is part of the reality, but if we look at the whole reality, can we deny that our people have cardiology problems and that it is on the rise? We go back to education, to prevention, and in the meantime we leave those who are sick alone? I agree: we have many basic problems, but we also have many diseases that need to be addressed and basic education and sanitation will not solve them. Do we just ignore them? We pretend this person has no coronary heart problem? This is a lifestyle disease, but this is also a genetic problem. Do we want a situation that only those who can go to the United States will be able to address cardiology problems? We cannot just go for vaccination to solve the health problems of the Philippines, although that is certainly part of the solution.

Sunfu: Some of our public policy advocate-friends admire their mentors in PGH because some of them like Nelia Maramba, Romy Quijano, Art Pesigan, Isidro Sia pushed them to go out of Metro Manila as part of their medical education training. Do you like this method of encouraging our medical students to serve in rural areas?

Yes, but you see many of these doctors leave for the provinces when they just finished their internship. They still lack the experience and expertise.Many go to the provinces filled with idealism, but when reality strikes home, when they get married and have children, many will reutrn to Manila because they want their children’s education in Manila. Those who stay in the provinces and rural areas, many also do not anymore pursue a specialization. My argument is we need more specialists in the rural areas, we need to get more doctors, more specialist doctors, out of Metro Manila. Metro Manila doesn’t need more doctors. This is why I always hope, regardless of who is secretary of health, he or she will go to the rural areas and see the health situation of the Philippines with these far flung areas in mind.

Sunfu: What can they do for us in the United States in cardiology that we can’t get here in the Philippines?

Nothing. If you are talking of surgery or diagnosis, it is the same. Up until the 1980s maybe, many of the rich still had to go to the United States for their heart surgery. No more: they don’t need to anymore, and fewer are going. Imagine when I trained in the US in the 1977, one of my professors said: why are you coming here to train for coronary bypass surgery? Is that going to do your country any good? We are far from those kinds of questions already.

Sunfu: What made you come back to the Philippines from the US?

I never wanted to be in the US.

Sunfu: Many PGH people don’t come back from their training in the US.

No, PGH people still come back. But I guess you are correct: many don’t comeback. We also have to admit, the concept of doing something for the common good is getting to become less and less important in the lives our countrymen, or even globally.

Sunfu: Was it important when you were young?

Yes, definitely. My father, who was a medical doctor of the Chinese General Hospital, a cardiologist, I cannot remember him at any time not thinking of the common good.

Who was the most influential doctor in your education?

That is an easy question: cardiac surgeon Manuel Tayao is my biggest influence, because he was technically simply an excellent surgeon. He took me under his wings. Part of the confidence I have now in my profession is because of my training from Dr. Tayao.

Sunfu: Do you come from a family of doctors?

My father was a cardiologist, and my son is a cardiologist, and he finishing his training in the US. He will be back soon. And I think he will be a better doctor than me or my father.

Sunfu: Spoken like a true father.

(laughter)

Sunfu: Who are the cardiologists you would trust with your life?

Dy Bun Yok and Rody Sy. My son. Just as my father trusted his life to no one else but me, the time he needed bypass surgery, he would have it done only if I would do the surgery. In the same way would I trust my life to my son.

Sunfu: There is the Sunshine Act in the US that has changed the pharmaceutical industry. What are your views on the pharmaceutical industry in the Philippines in relation to the medical community?

Well, the intention of bringing down the prices of medicine is very important. In the United States pharmaceutical companies are not even allowed to give out ballpens. Here in the Philippines I like to see more of this happen, or at the very least, I think we should draw the line between needs of the work place, like big conferences that need the assistance of big companies, and personal needs, like the need for a driver on a Sunday morning to go to the market, for example. Doctors should be very conscious of this line. But realistically, there are many things the medical community cannot afford if it is not supported by pharmaceutical companies, like conferences or brining important speakers from abroad to the Philippines. No doubt some companies have also been so aggressive that doctors become beholden to them. Some doctors have become very dependent on these big companies. That is too much. Slowly, we must move away from that dependency. For the medical education of the community, I am still okay with that. Personal needs or wants, there should be no more room for that.

Sunfu: How have you changed in your four years as Executive Director of the Heart Center?

I used to be focused on the problems of the Heart Center, and now that I work with legislators and regional hospital administrators, I realize the solution is not to solve the problems of the Heart Center, although there is that which we need to attend to, but the problem is much bigger: we have to go out of the Heart Center in order to address some of the biggest and most urgent problems. In the local level here at the Heart Center, we have patients from the provinces come here at 4AM to fall in line, and we get overwhelmed every day. Fixing this problem in the Heart Center level is not going to work, it is not enough.

Sunfu: Any lessons you did not know before you got this executive position?

I am fully convinced there is no reward in working for government.

Sunfu: Psychological rewards for doing good?

More frustrations than rewards, really. Cabinet secretaries get maybe P80,000.00 a month. It’s a lot of sacrifice when you consider what most of them were getting before they joined government. I have heard of marriages breaking up because of the sheer demands of life in government. If you intend to work in government and be honest, you must accept that indeed it is going to be a big sacrifice.

Sunfu: Well, the two times we saw you moving around, we saw a man with a lift in his walk because you seem to have a strong sense of purpose in your work. Is this a wrong impression?

I am a man with a purpose? Ok, but happy? No. This is a big sacrifice. Is it stress? No, not stress, as stress is everywhere and it will depend on how you handle or take stress. I think the environment to do excellent work is just not there. You are held back or weighed down by naysayers. I was still new as executive director, and I already had five cases filed against me with the Ombudsman. The threat to the institution is not from without, it is from within. As I said earlier, the concept of the common good is hardly there anymore, and it is not happening only in the Philippines, it is everywhere.

Look, Philhealth is very good, but the threat is also from within, from doctors. Doctors are earning good money already, but why make false claims in Philhealth? I cannot understand. I tell young doctors do not look at the health problems of your patients as a business opportunity. It is not a business opportunity. I believe in the old Chinese concept that you don’t have to make a killing in one transaction to earn, you do not overcharge. I have been faulted for interfering on the professional fees of doctors, but I feel they are charging too much.

Sunfu: Maybe the Philippine Heart Association is the venue for this. Are you an active member?

I never had a major role in the Philippine Heart Association. I think it has lost a lot of its social relevance. At one time I told a president of the PHA that we should do something about the ethics in the practice of cardiology, but he said we will step on a lot of toes if we touch on that subject. And that answer made me lose interest in the association. I began to see it as a social club. Maybe there are too many doctors, maybe competition is just too much, and some feel you have to take short cuts in ethics to get ahead. So I tell young doctors: don’t forget the very reason why you became a doctor. Nobody should become a doctor to get rich. Don’t lose your idealism. Illness is a misfortune that befalls our patients, it is not a means for us to get rich. Doctors are not meant to be businessmen. Do not lose the sense of compassion. A lot of doctors will not like what I am saying, but this is what I see. I tell the young graduates they must strive hard to uphold the dignity of the profession.

Is the Heart Center in the black?

Yes, we have been in the black for a few months now. There was a time we were in the red for maybe 15 years.

Sunfu: How do you assess PGH?

PGH is really out there in the front line solving the problems of the country, and I am sadly out of touch with the PGH, but I am happy to hear they have a big budget now, which should be able to make them go about their work more effectively.

Sunfu: We always end our interviews by asking what books or authors you would like to share with our readers?

I don’t like autobiographies and history books. I like fiction more. I read Scott Turow, Richard North Patterson, Nelson DeMille, Richard Russo. I read for entertainment. I don’t like self-help books, how to gain wealth and influence people books. I used to read medical journals, and now I read them only to fall asleep. Two pages and I am out. I got the book MBA in Ten Days when I assumed this position, but I am almost done as Executive Director, and I haven’t opened the book yet, so I am still not an MBA. Oh, there is an autobiography I like. Stolen Lives by Malika Oufkir, which is about living a charmed life in Morocco and being imprisoned in a penal colony for 20 years when her father was implicated in a plot to assassinate the king. It is worth reading and I am going to lend you the book. When I go to a bookstore, I look for the seal that a book has been chosen by this or that reliable book club, and it helps me shorten the process of looking for something that may be new, or interesting, or just plain entertaining.

Interview: Reynaldo Joson, MD (Surgeon, Policy Advocate, Mentor)

Reynaldo Joson, MD

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg is consultant in Health and Medicine, Hospital Administration, Hospital Safety Promotion and Disaster Preparedness, Medical Education, General Surgery and Surgical Oncology (Breast,Thyroid, Head and Neck, and Skin and Soft Tissue). We decided, as our year-end interview, it would be good to hear from a 2007 Xavier Kuangchi outstanding alumnus, to remind us what we are all, medical doctors and other health professionals, in health care for. This is our first interview to be done via email, and we decided not to do any editing to preserve the flavor of Dr. Joson’s language and rhythm.

Dr. Joson, thank you for the honor of having you for our website. How long have you been practicing medicine?
Officially, since 1975, the year I passed my Philippine Board of Medicine Examination. That’s 39 years.

What surprises you still about medicine?
Nothing now as I have accepted the reality a long time ago that medicine is not an exact science; nothing is absolutely certain or predictable; and that anything is possible in terms of disease occurrence, diagnosis of disease, response to treatment, and prognosis.

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.
In terms of outcomes of care, particularly, quality of life management and in the aphorism, “cure sometimes, relieve often, and comfort always”, the Philippine health care capability in terms of cancer is at par with developed countries. Protocols in the United States may be different but not necessarily superior in terms of the aphorism I mentioned earlier.

What are your criteria for you to call someone a good doctor?
Holistic, professional, and compassionate.

How about doctor-teachers, who have been important to you? Please share some names and why.
The late Dr. George Eufemio from whom I have imbibed the pragmatic approach in the practice of medicine and from whom I have imbibed the importance of medical photography. Dr. Antonio Limson from whom I have imbibed the virtues of humility and respect for students,

What excites you about your field today?
My field is healthcare delivery system in the Philippines. What excites me is to develop a medical center what will provide integrated value-based healthcare delivery services. I believe this is what the citizenry is looking for now and will be looking for indefinitely. Integrated Value-based Healthcare Services are services that improve health care outcomes per unit cost of care through integrated management systems. They use integrated management systems to create value in the delivery of health care services.
For every healthcare service rendered, on the part of the patient-clients, there is a perceived value for the money spent.
Cost of the service may be the running rate or higher. However, as much as possible, efforts must be exerted to bring the cost down to reasonable and acceptable level to both the clients and healthcare service providers.
Value is usually defined as health outcomes over cost of delivery of the outcomes.
The adjective “integrated” is used to emphasize the need for optimal integration among the different healthcare services and providers so as to produce excellent health outcomes within reasonable and acceptable cost.
Integrated value-based healthcare services are expected to lead to patient-clients’ delight.
With patient-clients’ delights, the hospital will be more attractive to the community.
Being more attractive, the hospital will have more patient-clients’ seeking its services which in turn will promote sustainability of the hospital.

Are any of your kids going into medicine? What do you tell them, lessons from your life?
I have only one kid who is now on his 2nd year at the University of the Philippine College of Medicine. I have told and advised him a lot of things already – on how to live life and on how to be a good physician. Make a life plan as early as now, target 70 years, implement the life plan and try to achieve the goals and objectives in the life plan even before 70 years. In the life plan, there are two goals: to survive physically, financially, and mentally and to enjoy whatever is placed in the life plan. On how to become a good physician, make strategic and operational plans; know the criteria of being a good physician – holistic, professional, and compassionate; be a self-directed learner.

What do you tell your residents?
Be holistic, professional, and compassionate physicians.
To answer your question, I suggest you get the answers direct from the horses’ mouth – the residents created a song “Josonics” as a tribute to me in my retirement from the Philippine General Hospital, which is available on youtube.

You have been associated with PGH, Manila Doctors, and Ospital ng Maynila. Give us an assessemnt of these three institutions, crucial to the health care system of the country.
Philippine General Hospital is a national government hospital. Ospital ng Manila Medical Center is a city government hospital. Manila Doctors Hospital is a private hospital. They are all parts of the health care system of the country, particularly, in Metro Manila or just Manila where these three hospitals are located. All these three hospitals are trying their very best to accomplish their stated vision and mission in the midst of continual challenges in the community such as changing health trends; rapid advances in medicine; changing economy, political, social, and regulatory environment; competition; market (both clients and labor); technology. As long as there are good leaders and teamwork of the workforce, they will continue to operate and contribute to the health care delivery system of the country.

Please give us a few names of authors or book titles you would like to share to our readers.
In terms of books, honestly, none. I am not an avid reader of books. I do write a lots though. I usually initiate my writings using my brain rather get ideas from books and the Internet. The readers can just Google “ROJoson (then key words of topics).” My writings cover topics in medical education, surgical oncology, hospital administration, hospital safety promotion and disaster preparedness, how to live life, quality management system, etc.

Interview: Reynaldo Vea, PhD (Academic Administrator, Engineer, Scholar)

imgres

We have opened discussions in our website with all kinds of leading medical doctors, and with the best among them, there is a clear recognition that for our health care to improve, we have to have thriving manufacturing industries (good jobs are crucial to good health), research (to be at the cutting edge of knowledge for health, but as a consequence in order to start real manufacturing), and quality basic science education (in order to build a culture of producing goods and knowledge). We are starting a series of interviews with those who can start the conversation from a non-medical doctors point of view, from academics, industrialist, politicians. We start this series with Reynaldo Vea, Ph.D, who is the President and CEO of Mapua Institute of Technology. He graduated from the University of the Philippine with a degree in Mechanical Engineering. He earned his Master’s Degree in Naval Architecture and Marine Engineering at the Massachusetts Institute of Technology, and his Doctorate Degree in Engineering at the University of California at Berkeley.

You are an engineer, teacher, administrator, scholar: which one is your predominant role for you?
First and foremost I have always been an administrator of schools. I did professional practice for a short time, but never in the Philippines. I designed off-shore supply vessels for the Gulf of Mexico. I designed container ships and tankers as well in San Francisco. But this was not for any long period, as I immediately came back to the Philippines to begin my academic career in the University of the Philippines.

What was the motivation in coming back to the Philippines after having earned your degrees in the United States? Or did you belong to the generation that still wanted to come back?
Basically we wanted to contribute to building the research capability of the country. We did hear about many coming back and getting very frustrated because the research infrastructure was not there, and so they go back to the United States. We wanted to break that cycle. When we came back, there were no vacant positions in UP, and they could not give us the title assistant professor. We jokingly referred to ourselves as api , the Filipino word for oppressed, which we used as an acronym to stand for the association of permanent instructors, because we were still pegged as instructors in the University of the Philippines, in spite of the fact that we already earned our masteral and doctorate degrees. But the administration moved quickly and gave us support.

Engineering is now the priority for many things and programs in the University of the Philippines. During the term of President Gloria Arroyo, she donated a big sum for the infrastructure of engineering.
Yes, but it started long ago, it was a long process, which we can see the fruits only now. During my time there, in the 1990s, because the stars were somehow aligned that the president of the university, Dr. Emil Javier, is a scientist; and the President of the Philippines was Fidel Ramos, who is an engineer: it was at that time that the concerted effort to build the student base, the infrastructure, the profile of engineering was really strongly pushed. We presented even at the level of the president’s cabinet as to a national vision for the University of the Philippines School of Engineering. The land earmarked for engineering where the buildings are now being built came from that time. But a lot of ground work was also already done at the time of then Dean Francisco Viray, who I served as associate dean. Dean Viray of course eventually became Secretary of Energy during the term of President Ramos.

Do we have research projects from the University of the Philippines that we can show the world and be proud of?
From what I have read of what are on stream, we may not be in the map yet, but for sure we have the PhDs who are capable of high quality research. I have no doubt something will come out of it, but we also have to set up the infrastructure, which I think they are doing in the University of the Philippines, for the commercialization of the research output. There is a real and credible improvement moving towards producing very high quality research. There is a technology transfer office now in the University. In the area of Radio Frequency Identification (RFID), or the transfer of data using the magnetic field, there are interesting advances. In the area of optics in hard disk drives there are also interesting advances.

When we train great engineers, do we have jobs for them when they are done with their studies?
The semiconductor industry and the electronics industry have been pleading for more and better engineers all the time. They are crying out for people who have advanced degrees. Of course if we want to move up the value chain in electronics, we will really need engineers who have advanced degrees.

Are we still at the level of assembling chips?
No, we are already producing products based on chips that are competitive globally. Integrated Microelectronics Incorporated of Ayala is ranked eighth worldwide in the microelectronics industry, which is great, but overall the developments have not been fast enough.

Is manufacturing still possible in the Philippines?
I think the stumbling block right now is China. They still manage to manufacture at a very low cost. It will be very difficult for us to compete. However, the wages in China are said to be rapidly increasing, and maybe that will present us with an opportunity. But we can’t just have the engineers, we also have to have highly trained educators, researchers, managers, industrial park designers. It takes a lot to have that system, culture, and infrastructure that can produce ground breaking technology-based products.

I have heard Dr. Roger Posadas arguing that South Korea and Taiwan are great models for the Philippines, but I argued that the United States poured in large amounts of money to help these two countries because of the cold war politics at that time.
Well yes, there is one factor that we don’t have; there are no Filipino engineers and managers in significant numbers, and if we have them studying and working abroad, we want them to come back and sacrifice, and with government support, to build and innovate here.

Morris Chang is an incredible story, of bringing chip manufacturing to Taiwan. He isn’t even an entrepreneur, but with government help, he was able to build Taiwan Semiconductor Manufacturing Company Limited (TSMC), which has become a global powerhouse in manufacturing.
They did a study in UC Berkeley and they took snap shots of the first and second generation leaders in research, engineering, and management of Silicon Valley. The Filipinos are just not there in substantial numbers. While people from India, Taiwan, Japan, South Korea are there, and many of them went back to their country, using their connections in the United States, to build industry in their home countries.
We also need to scale, as the UNESCO benchmark would say we need 34,000 research scientist and engineers for our population of 100 million, and DOST last calculated that we only have 13,000. So how do you jump from 13,000 to 34,000? And the ideal of course is for that 34,000 to have PhDs. We can do it in 10 years if we produce around 2,500 PhDs a year: again, the question is how do we do that? You have to send out at least 2,000 scholars to do their PhDs every year. The government we now know has the money, but the money just ends up in the wrong hands.

Will these engineers come back if we send them abroad to study?
The record has actually been good. I worked administratively as associate dean to send 20 scholars abroad for their PhDs, and everyone came back, except for one, and the only one who did not come back paid the University for his studies. We should not be scared. People do come back. To stay here is not only a question of monetary rewards, you also have to give them an environment where they can find fulfillment.

So when they come back, don’t get them stuck in teaching Physics 101?
Or worse, make them academic administrators. (Laughter)

How does the University of the Philippines compare with say other top ASEAN universities like the National University of Singapore? Are we okay?
Yes, no doubt we are okay. Our problem is we have too few of our students and faculty going out for their PhDs. But those who do go out to earn their PhD, most do well academically, so that is already an indicator that we are not missing anything in our own universities. I myself when I went to the Massachusetts Institute of Technology found that my training here in the Philippines prepared me well for what I had to face abroad.

In going to MIT, what struck you most that made you realize, this is a First World institution?
For sure it is their research. Of course when in UP we were analyzing motion of bodies, for example, in 2D, while in the MIT it was already in 3D, so there was the facilities advantage, but this was because this was MIT, as most universities at that time in the US were also still using 2D. And of course in their undergraduate engineering, they already had advanced engineering mathematics. But other than that, there is not much difference. I do remember they did really overload the students with reading materials.

When you say overload, does this mean it was still humanly possible to digest all the materials given?
No, impossible to digest everything. But that is the atmosphere they want, the atmosphere is very competitive. The best will survive. The system in MIT was called being graded on a curve, so some are sure to get As, and a certain number flunk. They like to say getting an education in MIT is like drinking from a fireman’s hose. You won’t be able to catch everything.

I remember listening to an entrepreneur who has made it big saying the only advantage he had of going to MIT was that in college in another university, he was thought of as the smartest guy in class. When he went to MIT for his masteral degree, his first exam grade was so low, he ended up locking himself in the dorm to cry. He said the humbling experience has been good for him.
Oh yes, there are many stories like that. It really happens.

Is this why some of the research of their graduate students are good?
Yes, but it is not just that: but there is a whole organized effort to support, publish, commercialize the research results. You become just part of a large undertaking. Even if you just contribute a small but original research to this large undertaking, then you become part of a big breakthrough. It is not just one individual in a lab, although there is that as well.

How was your transition from U.P . to Mapua?
Well, when I first came I had the reflexes of an administrator of a state university. Mapua’s existence is only made possible by its wits, since it is a private enterprise, meaning unlike a state university which will always have a budget no matter how small, we have to find a way to generate resources to keep the school going and to keep upgrading. I have been lucky that the stockholders of Mapua have been very supportive. In my first year here there was hardly any computer, within a year we had almost 2000 computers. We were the first to get a gigabit network, when no one else had one. We invested a lot in infrastructure. Our proposals to keep improving the standards are all supported by the school’s owners. Of course UP has changed now, and faculty can also now propose ambitious projects. We were also the first school in the Philippines to be accredited by the US-based engineering school accreditation body. We have also raised the profile of the faculty. We now have the full-range of the masters programs in engineering, and we have five PhD programs.

What kind of engineers does Mapua produce?
I think we produce engineers that are out in the field, the problem solvers of the industries that require engineering. Our students, when they graduate, I think tend to stay in engineering for a long time. But we also want to go beyond that, and so we have a building that will be finished soon, which is a building that will be devoted to research.

Are we able to retain young engineers in the country?
Many leave, but what can we do but to keep training engineers.

We are a population of 100 million. Even Israel, a very small country, admittedly a great recipient of US money, has been able to scale their software development for example. People were saying in that Roger Posadas talk in the Diliman Book Club that maybe what we have is a cultural problem. The culture of consumption is just too strong now, for example.
If you read Nick Joaquin on our supposed culture of smallness, maybe there is some validity in that. We are not ambitious enough. Japan in the 1950s was being laughed at. People said, don’t even buy toys made in Japan, as it was supposed to be of such bad quality it was dangerous to a child’s health. Samsung of Korea was considered low end.We have to want to make it badly enough, the way these countries did when they decided they wanted to become an export-led industrial country.

Maybe we should just give up, for those of us interested in manufacturing. I read an article where John Gokongwei said the best chance of the Philippines in manufacturing was up to the 1970s, and after that, the chance passed us already. Dado Banatao in the ASEAN Integration forum organized by the AIM basically answered my question by saying it is impossible for us to have a real manufacturing, since even Singapore has given up on this.
I disagree. The story is never finished. No outsider would have been able to predict the South Korea of today just 50 years ago, or the China of today just 30 years ago. The face of manufacturing is changing. If you can plan for the coming changes, like hyper automation, maybe you have a chance. The systems and process do not remain static and unchanging forever.
For me we just have to get the politics right, maybe that is not the right term, but we need some kind of process of maturation. We must also remember that the story is not yet over. Countries which supposedly got it right, also sometimes unravel all of a sudden; those considered hopeless are suddenly emerging as industrial giants in spite of say their size, or previous leaders.

What can industries do?
I think industries should just tackle the basic issue of productivity, we have to increase our productivity. We have to educate our labor force to be better, more productive, and more imaginative.

If you look at the instability of economies in Europe, you can see the most stable is Germany because of manufacturing. In Asia, Korea is also powered by manufacturing, even if they are greatly threatened by China.
Yes, you really need to create things. Harry Turman, after World War II, when he was president of the United States, asked what were they going to do now that the war was over and there was so much they had developed in the sphere of technology because of the war. Vannevar Bush, the inventor of the radar and vice president of MIT, answered in his capacity as one of the key advisers on science to the government, that their national mission was to dominate commerce through science and research. Basic research in schools and applied research in industry have become cornerstones in the rapid growth of the United States after World War II. You really have to work on the basic science before you talk about anything else. We must also realize that it did not happen overnight for the United States. There was a lot of preparation and confluence of events.

What books would you like to share with our readers.
I forgot the title, but there is collection of science fiction stories by MIT professors and students I thought was very good in showing me the future, or at that time the immediate near future. I thought the collection was amazingly accurate in many of the speculations of the authors about the future. Nicolas Negroponte’s Being Digital may be a bit dated, but I thought it was very perceptive in showing the relationship of technology and society. These two books I would recommend to anyone interested in issues about technology and the future.

There is now some criticism of these young and new billionaires channeling their wealth to space exploration and some such grand projects. Some argue the money is best spent elsewhere, and these capitalists are now determining the science agenda by the sheer fact that they have the resources. What do you think?
Science is always about exploration. I am all for it. If we stop exploring, what will happen to the human species?

Many of the doctors we have talked to, like ophthalmologist Harvey Uy, like you, talk a lot about the need for a good basic science education. Please give us an idea what is a good teacher. Who are your good teachers in engineering? Why were they good? What is a good basic science education?
Edgardo Pacheco and Oscar Baguio were my favorite engineering teachers. You take their exam without a calculator or a slide rule, and maybe you can finish the exam in 15 minutes. They were not worried about your not having to do a lot of numbers crunching, but it is really the principle behind the problem that they want you to understand, not the numbers crunching. I look back and realize their exams were really elegant and well-thought out. They were very committed teachers. They really provide students with the right environment to learn. You could really see their commitment to teaching.

Interview: Kenneth Hartigan-Go, MD (Acting Director General, Food and Drug Administration)

Go

Kenneth Hartigan-Go, MD is the Acting Director General of the Food and Drug Administration of the Philippines, and was founding Executive Director of the Dr. Stephen Zuellig Center for Asian Business Transformation, where he is a non-resident research fellow, at the Asian Institute of Management.

Are you, like National Scientist Ernesto Domingo, a believer that universal health care is possible in the Philippines?

Yes, I believe that because there are models out there that have been successful. We can just follow or adopt. Business must moderate its greed for this to work.

Shouldn’t government, or a strong government, be the one to moderate its greed and moderate the greed of business? I mean capitalism is about greed.

I think if we are to rely solely on government, we are in trouble. I believe business is changing in that social responsibility is now part of the equation. The private sector has an unending capacity to renew itself and improve. Government is just there to implement rules, but my belief is government should not be too involved with intervening on the conduct of the private sector, but government must protect the public at large from unscrupulous groups that do not respect the rule of law. Self-regulation or voluntary compliance to sensible rules makes more sense for me. Government must, like in China, plan strategically with a generational perspective, rather than a one-year or five-year perspective. If you want a heavily interventional government, it becomes a top-heavy government, and you necessarily have to answer the question: where do you get the quality people to man all these positions in government?

Even so, assuming we have a non-interventional government, we still don’t have the people in government, right?

Well, we have to qualify what kind of people we want in government. We must attract people who are not just into crafting policy, because I think we have enough people who have the education and desire and skills to craft excellent policy. We don’t actually need more policy. We need people who actually want to implement programs, unafraid and unapologetic about continuing all the good programs of his or her predecessor. You will not trust a military general to command an army on the battlefield who has not implemented or experienced an actual battle plan. You cannot risk the lives of foot soldiers in his hands. It is the same with government agencies: appointments must be made on the basis of the implementation record or execution ability of the person who will enter a department or agency; you cannot just hire on the basis of brilliance, or even brilliance with policy.

There is some criticism that the current Department of Health may be too focused on medical equipment upgrades, rather than public health issues and policies.

To balance that off, people may be forgetting that in the area of health care, equipment is also not only necessary, but important in attracting medical doctors and nurses to stay in a poorly resourced area. There is obviously an over concentration of health workers in Metro Manila, and the efforts to upgrade medical equipment and facilities may actually be a good strategic plan of trying to balance the manpower concentration from metropolitan cities to far flung areas and improve clinical services. We also should not expect our doctors to want to be barefoot doctors. A tipping point of some sort is necessary in order to get people to want to relocate outside the centers like Manila and Cebu.

I read somewhere that you are excited about the 2014 UP medical students who are required to serve in the country for three years, why not hire from that pool of graduates?

I think you may be referring to the return service agreement of UP med graduates and actually 2014 is just the start of the program. They are not required to do service in the country: they are just required to stay in the country for the next three years and that is already interpreted as fulfilling the requirement for having studied in UP-PGH. Of course that opens many good and exciting possibilities for them and the country; but I also heard there are graduates who are also asking lawyers to look into the legality of the contract. I think the requirement is good and necessary, because taxpayers paid a lot to have them educated in the best medical school in the country; at the same time I also don’t want to overplay the possibilities, because the person can just stay in the country and take up ballet lessons, not practice medicine, and still that person has fulfilled the requirement already.

Is that enough for you, just staying in the country?

No, of course it is not enough. You took a slot from someone who may not be as academically gifted, but willing to serve in the rural areas, and we certainly prefer that student who is willing to stay in the Philippines to practice. The country spent a lot to get a student through medical school, the least he or she can do is actually put in service for three years, at the minimum.

Are you happy with Philhealth?

Yes, but our whole health policy is largely still curative, not preventive. We have to give more attention to preventive plans and mechanisms: hospitals should be the last part of the line of defense, or last part of the program. This is the reason there is optimism for private public partnerships, because it unburdens the government of some of the overhead and it can concentrate on other priorities and concerns.

On our part in Sunfu, we are skeptical about the private public partnerships because,for example in laboratory equipment, suddenly you have a capitalist entity inside a government hospital. Of course the push for the capitalist entity is to get the Return on Investment as early as possible, and we don’t want to be in a position where we will be tempted to push doctors and medtechs to keep using our laboratory equipment even if unnecessary or disadvantageous to the patient. The temptation to corrupt people will be high for a private entity that has a lot of investments inside a public health facility.

Okay, yes: but we can’t continue doing things the way they were done before and expect good results. We need radical solutions, which the late Quasi Romualdez was looking for when he became secretary of health. We need to change fundamentals, we have to sell to people the idea that the good of society is always part of the equation, that it is good business. The problem really is we don’t call out people who are corrupt, but maybe that is where education fails. Maybe this is where government should give reasonable timetables for reasonable ROIs, in order to moderate, as I said, the greed of the private sector.

Our company tends to believe in strong government: although worldwide, even the founders of Google have said, the medical industry is over regulated, and as a result, many people, innovators, refuse to go into exploring businesses and innovations in the area of medicine and health care. Maybe education is the solution?

If you mean sending government people to institutions of higher learning, I have seen the government send out a lot of people to study, here and abroad. I think it is only half the solution. The whole environment just doesn’t support the technology and radical initiatives innovative and out-of-the-box people bring into government, so people just largely give up. We need street-smart implementers. This was the approach of the late Quasi Romualdez as secretary of health, he got young people, brought them to Baguio, and told them to craft a reform agenda. When we got back: he said implement it. I realize, now that I am older, the hope is really in the young, not us the old. In your interviews, you should be going after the young, not us the old. Maybe you want to interview the old for inspiration, but the game-changers and possible game-changers will come from the youth. For one, the young have the trait still of being embarrassed, and that is necessary and important for us to move forward. We also need horizontal implementations and coordination among our planners: we are very vertical in the way we plan. We need people who are able to do interagency planning for our country to become more efficient. We lack this skill very much. At the moment, we are also very reliant on donors.

How about clinical trials? Is this something we want to attract? This is big business.

This question requires a complicated answer. There is a big business and health potential, but we are wasting it because of over regulation and our lack of technical capacity. There are groups against clinical trials. But if you look at the history of science and medicine, from research to animal trials to human trials, it is a long and expensive process. There are a lot of bureaucratic hurdles. There are of course the fake clinical-trials, which is really a market seeding operation, where a company gets to pay a doctor for prescribing drugs in the guise of a trial, but is actually only a technique for companies to give money to the dispenser of drugs in order for that person in authority to prescribe and get into the habit of prescribing their drugs. At a stroke of the pen, we think we have largely stopped this. We have disallowed this by issuing some guidelines and definitions of what is a legitimate clinical trial. Many companies are thankful for this, because they are no longer forced to go into this, because their competitors have stopped the practice as well. This is a way of bringing down the prices of drugs.
Now there are the legitimate clinical trials. We hope to post them in our website, those that are approved clinical trials. Clinical trials can be a good and legitimate way for our country to earn revenue, but more importantly for me, indigent patients get a chance to use drugs that they do not have a chance to try if they are not part of the clinical trials for say AIDS or cancer. In a certain country with quite an advanced economy, there are hardly any patients who are pharmaceutically naïve, meaning people whose bodies have not yet been used for some kind of clinical trial. We have groups here in the Philippines who are angry that people are being used as guinea pigs, but medicine really has to eventually be tried on people: this is done all over the world, in Singapore, Thailand, the United States. Some countries have been taking advantage of this, except their population is so small, and many or most have gone through clinical trials already; so they tell us, we should take advantage of this opportunity. If we have clinical trials here, and the drug gets approved, the approval time will also be shorter and cheaper, because it already went through our process here, and this is another way to bring down the prices of drugs.

The main problem is ethics, not clinical trials: self-regulation, and then regulation of professional societies are very important and crucial. Medical organizations should take away membership privileges or fellowships of medical doctors who cross the line. The government should not be the first and last organization disciplining professionals, yet many want government to do the job for them.

How about manufacturing drugs: do we have hope in becoming a smaller version of say India?

We don’t have hope in manufacturing. In drugs, we do not manufacture, we just compound. We don’t have the volume and scale of India. We just don’t have it. We also don’t have the critical mass of scientists, medical researchers, and professional managers. Sorry to sound so negative, but it is the truth. Our hope is to take care of our plant and marine diversity, and focus our effort in research on these. There is potential there.

Where do you get the motivation or inspiration to get things moving in government?

Anger. Dr. Manuel Dayrit, who was a great secretary of health, said you have to be detached to survive government and to get things moving. That is one way, but detachment may make you lose the sense of urgency. Outrage is a good motivation: it gets things moving.

Who were the teachers in medical school who inspired you?

A lot. I am afraid of mentioning some names, as there are so many of them. Dr. Nelia Maramba. She is a first-class scientist, a well-read professional, and a very good teacher. There is the late secretary of health, Dr. Quasi Romualdez. Of course our National Scientist, Dr. Ernesto Domingo is a great inspiration. There are many more.

Why quit from government after just two years of service? Maybe you should stay longer.

I don’t believe you have to stay long in government to do reforms. I believe in going in and doing good work as fast and as efficiently as possible. I also believe in the Chinese saying that you have to create a vacuum for people to move up. I gave myself two years, and my two years are up this October. The secret is simple, just listen to what people say about us: it tends to be accurate, what people in industry objectively share about their experience with us. We listen, and we try to adjust and institute improvements in the system. There are many problems, but we are trying to put our house in order. We try to implement innovations, we are trying to cut down regulations, and we are trying to continue good programs from the past. There is a lack of trust that things can be implemented, that positive things can be done, and we try to have that atmosphere inside the agency. But we must allow good people to move up, allow young people to have the opportunity. Political appointees usually look at building monuments, rather than generational planning. Not staying too long in government is a way of developing leaders also.

What are you going to be when you leave government? Are you going back to being a toxicologist? A medical researcher? A professional manager? A policy advocate? An institution builder for the Asian Institute of Management?

Hard to answer: but I will find out and I will tell you when I am finally out of government.

What is exciting you in the many fields you are involved in?

Nothing. Sounds jaded, but none at the moment.

Please share with our readers three books or authors that you learned from and maybe we can learn from as well. It can be related to your field, like medical books, but it doesn’t have to be.

If as a doctor all you read are scientific books of your field, it is the end of you: doctors must read outside their field. Malcolm Gladwell’s series of books I like very much: I found them helpful in seeing the world through the lens of anthropology, of how certain behavior shapes our decisions. The Tipping Point is the most interesting among his series of explorations. Rudy Gulliani’s biography I enjoyed very much. It shows a framework of working within government. His actions as mayor of New York were sometimes controversial, but were shown to be quite strategic and long-term in thinking and consequence. He is confrontational, but he used numbers to prove his arguments and explain why he took a certain approach, and not another. Tom Clancy’s Jack Ryan books are good. I am interested not in the conspiracies he unravels per se, but I like his fictional take that there is something more to what you see, and the protagonist shows a way of looking at the world in a different way. Of course it is too good to be true, but the novel way of looking at a problem, instead of being carried away by media or some hysteria, is a good way of finding solutions. It is good to be reminded that things are not always what they appear to be. Among local writers, Francis Kong I find to be inspirational and at the same time practical. He gave a talk to FDA officers. He touched the hearts of our people. He made a lot of sense: society should teach our people financial literacy, that people must be taught that money doesn’t grow from trees, and that there is an ethical dimension involved in issues about work and money.

Interview: Vicente Santos, Jr., MD (Ophthalmologist, Educator, Administrator)

Santos

Dr. Vicente Santos, Jr. is an ophthalmologist, president of Fatima Medical Center, educator and board member of Fatima University. No doubt he, together with his family, is a major force in the field of medicine in the Philippines, as a clinician, educator, and businessman.

You wear many hats in your group, which one do you enjoy the most?

First and foremost I am an ophthalmologist, but I enjoy all of them: I like teaching the undergraduates, the medical students. I enjoy doing strategic planning with our management team.

What is exciting you in your field right now?

I just got certified to do a procedure called SMILE, which is an acronym for Small Incision Lenticule Extraction, which is a technology that doesn’t, unlike Lasik, use a blade. Unlike Lasik, this procedure doesn’t need to open the corneal flap. I think there are around six of us certified, five in St. Luke’s Global, their refractive crew, and myself here in Fatima. This has been done 80,000 times already, so it is a pretty stable procedure.

Why should a layman be interested in this procedure?

20 million procedures have been done for Lasik, so it is a work horse in ophthalmology. The risk is minimal, but you also use a blade. A flap or blade complication is possible, even if remote, in Lasik, and this is not there in SMILE. But of course there is no such thing as there is no risk.

How old Fatima?

47 years.

How are you and your siblings different from your parents in managing Fatima?

We are more structured, more objective in our metrics. My parents relied on many things that were more subjective, like relationships, friendships, gut feel. We have professionalized the organization significantly, as a way not only of surviving, but of moving up and improving. We pushed the organization to go through certifications and accreditations. Although of course compared to us, our parents were much more hardworking and driven. Our family lived in the hospital for two or three years, precisely because they were that focused and dedicated, aside from the fact that it was at that time, during the construction phase our house was torn down to build the nursing school, and our ancestral home was being reconstructed.

Nursing as a college major, and the number of unemployed nurses have become problems in our country. You have seen it from both ends as a school that produces nurses, and as a hospital that employs them. What do you think should be done to solve this problem?

I think what the government did is correct: they put a moratorium on new nursing schools. During the peak of the wave of people enrolling in nursing schools, it was almost like people were putting a nursing school in their garage or anywhere they can set up one. That is happily not there anymore. Many have closed down. Enrollment fads come in waves, and there will be a next wave. There was a wave in the 1970s and 2000. There will be another surge because of the population growth, the opening again of opportunities in the First World.

Being a doctor and a hospital administrator: how do you assess Philhealth?

They are very reliable. The various complications in reimbursements are there, but I should say Philhealth is very reliable. We in ophthalmology are paid pretty well, I mean relatively well. For this reason, some have approached their practice by going for volume, while others have wanted to maintain a very high quality, disregarding the volume. But if you are a patient, Philhealth is willing to take care of your needs up to P16,000.00. That is not a small amount, and so hospitals and doctors give it importance.

What would you wish for Philippine health care if you could make a wish?

I would like to see more hospitals built outside Metro Manila. There are still many places that are underserved. Of course I also wish for the same quality that we have here in Manila to be the same all over the country. The WHO recommendation is for 15 beds per 100,000 people, we only have 5 beds for 100,000 people, so even if you double our current number, we are still far from the ideal.

Manuel V. Pangilinan’s group has been buying hospitals and many seem to be ready to put out the welcome mat to sell to them. Are you ready for them? How do you see them?

At the level of competition, of course it keeps everyone on their toes, and that is good. If your question is if we are going to sell out, the answer is no. Maybe for partnerships we are open, but definitely to sell out we are not open as we have worked very hard for years to build Fatima, we won’t just let it go. One can look at them as a threat, and of course that is true; but if we look at the vision, and if the vision of everyone is quality health care, then the threat may be overblown, because as I said, there is a shortage of hospitals and there is actually room for more, but of course we mean there is more room for quality services and quality hospitals, I don’t just mean an increase in number of beds.

Is the quality of human resources a problem? I am interested in knowing your views on this, again because you are in the education of the human resources side of health care, and with the hospital end you are employing these graduates.

Migration is of course a major problem. As soon as a person gets certified, meaning they can already do things at the level above the usual average, they leave or get pirated immediately. Then you start the retraining all over again. We are not just talking about nurses, but the whole spectrum of hospital people, medtechs, laboratory technicians, radtechs, everyone, even doctors. Happily, enrollment for medical doctors is up, there is a surge, and that is good news for medical schools, it is good news for the country, good as well for the global health industry, as it ensures continuity in the entry of doctors in the industry.

Your sub-specialization is retina. How are we in the Philippines compared to other countries?

No doubt we are at par with the best in the world.

What is your vision for Fatima?

We did announce that we hope to build a 150-bed hospital in Antipolo. We are looking for opportunities outside Metro Manila, we want a presence in South Luzon. Maybe even down in the Visayas. We hope for more expansion in the future.

Are the graduates of our high school system improving? You meet the intake of your school on a regular basis.

Yes, I think they are improving and there are a lot of efforts to improve the system. K-12 is a big move, and I think an important move. This is a very concrete move, and quite a sacrifice for colleges and universities, as our population of students would go down by as much as 50 percent for maybe four years. Information is also easily accessible now, and I think it can only help us as a nation to become better, to keep improving.

Who are the biggest influences on you as a doctor?

Dr. Mario Aquino for ophthalmology and Dr. Pearl Tamesis Villalon for retina. These were my mentors in St. Luke’s, and they were really great teachers, not just great doctors. In UERM the list is long, there is Dr. Joven Cuanang, there is Dr. Romeo Divinagracia; the names will be endless if I have to list each of them down.

What will surprise people about running a hospital?

I am not sure if there is anything that will surprise people about running a hospital: there is of course the possibility of making a decent profit, but there is also a large amount of spending to be done on a constant basis. One must be able to balance both in order to do well, and one has to manage the hospital well in order to achieve stability and income. There are a few groups getting money from doctors to put up a hospital, but some have failed to factor in the need for quality equipment, which is also very important.

What do you do outside medicine and management?

I like joining marathons and golf.

Which marathon have you joined that is most challenging?

I have joined the Lu Marathan du Medoc in the Bordeaux region of France, which is quite a challenge. This is a 42 kilometer run, and you have 21 stops where you have to drink wine and water. It was a lot of fun, but it was also very challenging, and actually very difficult.

How about as a golfer: are you good?

I cannot say I am good. But fortunately, in spite of that, I can say I have made a hole-in-one, and according to golf stats, it is quite a rare event, even among the masters. I made that hole-in-one just last March.

Do you have credible witnesses to this event, and did they sign the necessary papers as witnesses?

Yes! (Laughter)

Is this skill or luck?

(Laughter) Well, I am hoping it is partly skill. There are some people who say to increase your chances of doing a hole-in-one, you have to play golf every day for two lifetimes. Of course this doesn’t mean I am more skilled than anyone, because luck definitely had a role in it.

Is there any book you have read that you find very compelling that you would like to share with our readers?

Freakonomics: A Rogue Economist Explores the Hidden Side of Everything by Steven Levitt and Stephen Dubner. It reminds you of many things we tend to either ignore or forget. I also loved the book The Perfection Point: Sports Science Predicts the Fastest Man, the Highest Jump, and the Limits of Athletic Performance by John Breknus. This is a book that tells you what is the optimum performance possible of an athlete in a given event, assuming all conditions are right; it is very data and science driven.

I can see from your two recommended books that you are into facts, hard data, and what they mean in the science of the real world. Maybe that is why you are into marathons, you are into pushing the limits of what is said to be possible and optimum.

Yes, come to think of it, yes.

Interview: Ernesto Domingo, MD (National Scientist)

images

We are averse to giving long introductory bios for our interviewees. Credentials, especially long ones, are more of a bother than helpful in getting to the crux of the personality and views of the subject. But with Dr. Ernesto Domingo, National Scientist, we are obliged to take a portion from the Ramon Magsaysay Awards website introduction: “A well-respected but unprepossessing specialist in hepatology and gastroenterology, Domingo has always valued the social side of his profession, devoting over four decades to the University of the Philippines-Manila (UPM) as researcher, teacher, chancellor, and university professor emeritus. Passionate about science, he organized the UPM Liver Study Group and led in groundbreaking studies of viral hepatitis and liver disease which established the causative connection between chronic hepatitis-B and liver cancer. By determining as well the preventive solution to liver cancer—the immunization of newborns against hepatitis-B within twenty-four hours from birth reduces the probability of acquiring hepatitis by 95 percent—his research has saved millions of people from the danger of life-threatening illness, and reduced health care costs. Deeply concerned about the poor’s access to health care, he has pushed for hepatitis vaccination to be mandatory and available to all. Working closely with legislators, he has also successfully lobbied for a law that ensures annual budgetary support for neonatal hepatitis immunization.”
Sunfu Solutions, Inc. advocates for financially viable local government hospitals partly because we think citizens are primarily responsible for their health, and largely because fiscal responsibility means more money for local governments to improve health care, basic education, local government employee salaries (especially of health workers, which includes medical doctors); equally important, we hope public hospitals are not seen as unnecessary economic and political burdens best ignored, or at most attended to only during elections season. But our discussion with Dr. Domingo has opened up the important fact of social stratification, or his group’s great advocacy, that universal health care for Filipinos is a simple and serious answer to the social inequity in Philippine society. Health care as an important avenue towards solving the problems of the Philippine economic pyramid must be acknowledged, studied carefully, and in the long run, supported, implemented, and we in Sunfu Solutions, Inc. certainly want to be a part of that future.

What is exciting you in your field right now?

If you are talking about medicine, or the science of medicine, and my medical specialization in particular: I am no longer interested, so there is no excitement. I no longer give talks or accept invitations to be a reactor to scientific papers. It doesn’t interest me anymore. I keep up-to-date with what is new, because I still practice medicine, so it is my personal responsibility to know what is happening in my field. But what is exciting me right now, what is getting the bulk of my time is public health advocacy. I am trying to help in the efforts for a comprehensive universal health care system for the Philippines. The efforts to improve the system, make it more efficient, to have the funding for it; the sincerity of the Aquino administration in setting up this system, they are all helping me get out of bed every day. More than excitement, maybe I should say there is really a need to do this, and that keeps me occupied every day. This leadership in government, starting 2010, is serious about health care, and the health policy adapted by the bureaucracy is very progressive. We are actually late compared to our neighbors in this area of health policy. Kalusugan Pangkalahatan is the idea: health care for everyone, rich or poor, by virtue of just being a Filipino.
I have had too much of the science part of my profession: after training abroad, in 1967, I already started working in the University of the Philippines. There is very little I want to do in the science part of medicine.

Is Philhealth the universal health care that you are talking about?

No, Philhealth is only a part of this. To put it simply, by virtue of your citizenship, as a Filipino, if you get sick, you will be able to get the best health care provided by the country without dipping into your pocket.

Are we capable of this? Do we have the money?

Thailand has had it since the late 1970s.
Japan and Korea did it before they became First World countries. England declared universal health care after the 2nd World War, when the government was down, it had no money. They were able to do it. Why can’t we?
Philhealth is just a mechanism of paying, but it is only one of the many possible mechanisms. It is not the only model or mechanism. In England, there is a tax for health. In contrast, Philhealth is supposed to be a social health insurance. This is a development of Medicare, so Philhealth is a move forward, and we now have to co-opt it to move it towards universal health care. 12 million families are supposed to be covered by Philhealth, with no balance billing for certain health problems already. The only condition is the patient goes to a government hospital. If fully developed, a day will come when there will be no distinction between private and public hospitals. This is developing: it will attain maturity much later. It will not be immediate.

Ospital ng Maynila was mostly free at one time. It almost ruined the whole hospital system of Manila, maybe even of some surrounding government hospitals not under the City of Manila. Is it wise to have everything free?

You cannot have everything free immediately, for sure: if we have very rich local and national governments, maybe. But as I keep emphasizing, universal health care is not about just one mechanism, it will look for various sources of funds to answer the health needs of the public. England is via taxes, Germany is via the guild system, which means the employer shoulders it; in Canada, a province negotiates with central government and both contribute to make it possible for hospitals to be paid a fee for services rendered; Thaksin has his 30-Baht system, which means once say a farmer pays 30 Baht to a hospital, all is taken cared of to help him solve his health concern or problem.

Do we have the money for a universal health care system?

That is the eternal question. And the answer is certainly we can do it. If we can’t do it, we should abandon all our efforts towards achieving it. Only the United States and the Philippines are the two so-called free and capitalists countries that do not have universal health care. Look around the world, they are doing it. Go to Canada. England started in 1945. Germany started even before the war, at the time of Bismarck.
Costing studies have been done. It is not a question of money being available for the public to use them. It is a question of getting money from various sources and mechanisms, pooling them, having a national program aligned to the local programs, of doing a detailed cost study, and having an educated public use the pool of funds wisely. The implementation of the initial structures and various serious studies are happening now.
This is not a very good example, but P600,000 for example is allocated in Philhealth for kidney transplant: why is Philhealth doing this? Because some of those who need it are very poor and they cannot wait for the perfect system. They already have to allocate money for this; the way they allocate a budget for appendectomy, dengue, and so on. We want to support the coming of a time when we are able to cover fully catastrophic diseases that will wipe out an average Filipino’s financial resources if there is no support from the government. We cannot do it totally immediately, but we have to start somewhere, and Philhealth is doing that already because many people who are sick cannot wait for the perfect system and the perfect budget to come. The thrust of Philhealth is just the primary needs right now. This is just the beginning, but we are going already for the preventive and promotive, aside from curative.

Are these realistic goals?

This is not a walk in the park. We are all realists in the Universal Health Care Study Group. We did not enter this dreaming. The experience of other countries tells us we can do it; we see this is as a way to partially solve the problems of inequity in society. If health care and medicine are seen as commodities to be sold and bought, purely as commodities to be traded in the market, what happens to 60 percent of Filipinos who do not have money?

There are now local government hospitals registering an income because of Philhealth. As a result, they are able to give better services. Their staff, the nurses and doctors, also get to add to their income. Is this bad?

They are earning because of Philhealth, yes. Of course to earn is not bad, but maybe the bigger problem is the planning, as Manila I know has built so many hospitals, it is just not sustainable. I think the debate of devolution or reverting local government hospitals back to the Department of Health is not a healthy debate: it is already devolved and we work from there. But planning and coordination are important, projecting budgetary requirements is important. This is why I think Navotas City is unique in that they really went out of their way to consult many people and sectors outside Navotas on how they can set up a hospital and run it well. Some other local government hospitals have done it too, I am sure, but I am not aware of them.

To go back to your question: No, of course it is not bad if local government hospitals are earning money because of Philhealth. City hospitals are slightly different in that they have their needs and responsibilities that are outside the purview of the national government. They do not remit earnings to the national government and they do not rely on the national government for funding. They have to do their planning carefully and judiciously.

How did this involvement with Navotas come about? Are you paid by the national government or Navotas?

I was not initially involved with the Navotas project. It was actually a product of discussions between Dr. Quasi Romualdez and the Tiangco brothers, the Congressman and the Mayor. I only got involved later on, when the Universal HeaIth Care Study Group got fully involved. I have no official involvement with the government now, although the health secretary asked for my help to set up a research mechanism to evaluate, measure, and assess national health programs. DOH needs it for policy and program planning and implementation. They have the money for this. 2 percent of the DoH budget can legally be used for research. The question is can we absorb such a large budget? Can we use the budget well? At the moment, we are trying to put the system in place so we can do good research using this money. One thing I can tell you, dealing with the DOH has made me realize they have many very good people working there. All they need is support and the proper mechanisms to do good work. I have a very high regard for DOH, and not just at the level of the secretary and undersecretaries. I am talking about the bureau directors, the doctors, the staff.

So all the time you have invested in say Navotas is gratis?

Yes, the group doesn’t get any financial considerations from Navotas. We do not ask for anything financial, nor do we expect anything financial in return. It is enough that they give us a chance to exchange ideas, and they take our suggestions into serious consideration. Of course some of the members of the Universal Health Care Study Group teach in U.P., so in a way they are paid by government, but there is no direct link between the Study Group as a group to any government body.

I read some of the recommendations of the study group. Although we are a selling company, we have our advocacies as well. We find tie-ups and Public Private Partnership arrangements generally disadvantageous to the government, most especially to patients; like when it comes to running laboratories inside government hospitals. In effect, the government loses control over laboratories and pharmacies in the name of efficiency. We have strong disagreements with this, even though as a company in a capitalist system, this could work to our great advantage.

Well I do not think we have any recommendation on tie-ups or things of that nature that is definite or firm. It is all in flux at the moment. We are also still studying the options and possibilities.

You mentioned helping in the area of research for DOH, which is very functional in nature, meaning research in aid of program implementation. Don’t we need more science research?

Yes, but we will only have so much science research as we have serious science researchers. We also do not have enough people to create that research atmosphere. Of course there is a problem that those in U.P. who show themselves to be good in either teaching or research end up working or being promoted to administration, and that eventually hinders the research and teaching of these very good scientists and doctors.

I know Professor Edgardo Gomez of the UP Marine Science Institute is very much against the promotion of top-rank researchers to administrative positions.

Yes, like Dr. Gomez, I am also against that. In our department in PGH, when I was given the opportunity to head it, I broke from that. I designated as researchers those inclined towards research and had shown talent in doing the work. I did not saddle them with teaching unless they wanted to teach in the classroom, and promotions were based on their output, not teaching load or student evaluation. I remember many names: Augusto Lingao, Agbayani, Flora Pascasio. We produced many productive researchers because of that. It is a departmental decision what we did: it was not university wide. In the University, you must teach no matter what, at that time. That is not bad, but the ideal is to just leave it to the guy to decide if he wants to pursue a purely research track.

Yes, definitely it is a problem in our country: if you become a good researcher and teacher, you become administrator. Look at Eva Cutiongco, Menchit Padilla, and Dr. Bellisario. They get curtailed in their research. Many good research people also get attracted to administrative work, because it is a way of contributing to the profession in an immediate and practical way, and additionally, it is a sure way to promotion, of moving up in the academic hierarchy.

You seem to have done it all: teach, research, administration. And you seem to have done well in all.

There is a cost to that. It takes a lot. I did not become rich, as you can see. (Laughter) You have to make basic decisions on what you want and you set your priorities on the basis of those decisions. I love teaching. I love research. Two faces of the same thing as far as I am concerned: a teacher is more effective if you can share original research. But that is a personal inclination: the two do not have to go together. Yes, like Dr. Gomez, I am very much against the promotion of good researchers to administrative positions. In the end, it is likely counter-productive for everyone.

Going back to Navotas: you sound excited. Why?

Yes, because the leadership of Navotas is, like the leadership of the national government, very serious: they ask us for guidance. And we are trying our best. They ask many groups and people. They consult many people before they do anything, and when I refer to people, I mean they consult “neutral” people, people who only have the best of health care for the poor in their agenda.
We gave suggestions on size, what services, relationship with the barangay health centers, and we are even part of the process of choosing who will head the hospital. We give inputs. It is very exciting.

You seem to be quite familiar with the area.

I grew up in the Navotas-Malabon area. I left in 1976. The population of Malabon then was around 60,000. Malabon at that time had no squatting problem, as it was sparsely populated.

Did it already flood the way it does today?

No, not at all. Flooding only started when the spillways and rivers were covered and converted into Imelda Marcos’ Dagat Dagatan. I did a paper on that. Rivers and rivulets, water from storms went through those channels. It was fun, as kids we played with paper boats in the rivers.

My mother is from Navotas. My father is from Malabon. I grew up in Malabon. My siblings are all still in Malabon. I consider myself from Malabon, even if Quezon City is the place of my residency now. I am still attached to the area.
I went to the National Teacher’s College in Malabon for high school. I went to the Malabon Elementary School for grade school. I am a product of the public school system.

You also sound excited about the current leadership in the national government.

We never thought any government would ever take this issue of universal health care seriously. At the level of the President, he himself, when he gives a talk, I know he understands the problem and the concept of universal health care. President Benigno Aquino has a firm grasp of the issues and what it takes to solve the problems, and his marching orders to the Department of Health are very specific. This is not necessarily true of the other candidates during the 2010 elections. We are very lucky with this President. We are very happy.

Thaksin is loved by a good segment of the population: why? Because of universal health care. In some places, they are willing to die for him. The universal health care of Thailand appears difficult to reverse. If a universal health system works and works well in the Philippines, we hope it will be irreversible as well.

What is a good doctor for you?

A good doctor takes care of his or her patients, obviously. His primary business is taking care of those who seek him: he should be competent, that’s a given, he knows his science, his medicine. He has the interest of his patient, including the material well-being of the patient, at heart: meaning he must worry about the patient’s material resources. Note that I use the word worry. A good doctor must protect the resources of his patients. If a laboratory exam is not necessary, he must not require it, because you want to protect his resources. There must be a personal touch; it cannot be all science: after all, we literally do not cure, we just facilitate it. Curing is really beyond us. It is really about caring. It goes beyond a medical and professional relationship. While you are in practice, a medical doctor should participate in the social aspect of medicine, one must not just spend time doing your medical job or duties, but you should do your best to get involved in the social, political, economic issues of medicine.

How old are you?

77.

How do you keep strong and healthy?

I love work. I work very hard physically. Food I have likes and dislikes, but I am not faddish in what I eat. I do not choose this or that food because it is supposed to make me healthier.

We are constantly looking for good and cheap medical equipment. We feel expensive brands simply suck resources of Third World countries and we need plenty of resources to improve health care. We are somehow involved with the ventilator innovation of Dr. Abundio Balgos, hoping we could help in the manufacturing and dissemination of local medical equipment and devices. Do you think we have a chance still in manufacturing? Manufacturing of course means creativity and jobs, two issues we are also greatly attached to.

Dr. Abundio Balgos I have known him since his days as a medical student. I am not sure about the details of this project, but whatever he decides to do, he will do a good job. Since residency, once he accepts a task, he will do it, and he will do it well to the utmost of his abilities. Just on the basis of who is involved, I would say there is a good chance.

We always end our interviews by asking if there are books or authors you want to share with our readers.

I am more of a people person rather than a books person: I have been privileged in that I have met many good people, like Antonio Sison, Chuchi Herrera. By observing how they do things, without words exchanged, I learned about honesty, efficiency, focus. I don’t see all these in one person, but I see bits of it in many people, and I learn from seeing. For example, Dr.Oscar Liboro, I am not related to him, but he took me under his wing, he looked for opportunities for me to study abroad. When I came back, I had no money, and he said come work with me and when you are ready to go on your own, just tell me. Imagine that. After 11 months, I did that: I went to him and said I am ready to go on my own. And that was it, no problem, immediately it was okay, and immediately I started my own practice. From him, I learned about generosity. The doctor who contributed much to my professional growth was National Scientist Paulo C. Campos. It was he who enabled me to do many academic projects that turned out to be crucial to the kind of work I have pursued. And of course, without a good family life, especially a supportive wife, I will probably feel less fulfilled.

Interview: Margarita Lat-Luna, MD (Ophthalmologist and Deputy Director for Fiscal Services – PGH)

Dr. Margarita Lat-Luna (in black) with friends from PGH batch 1993

Dr. Margarita Lat-Luna (in black) with classmates from UP College of Medicine Batch 1993:  Dr. Ethel Tangarorang, Dr. Paolo Pagkatipunan, Dr. Beth Riel- Hollero, Dr. Michelli Gose-Yusay, Dr. Remelee Elegado, Dr. Tina Eusebio, Dr. Ma. Lora Cabrera-Tupas

 

Margarita Lat-Luna, MD is an ophthalmologist and current deputy director for fiscal services of the University of the Philippines – Philippine General Hospital. She is treasurer of the Philippine Academy of Ophthalmology and board member of the Philippine Glaucoma Society. A lot has been said about the strengths and weakness of Philippine medical education, we decided to seek out a practicing clinician, educator, and administrator of what is certainly a great medical training institution. We also wanted to know how the premier training institution for medical doctors is doing financially. The former president of the University of the Philippines system, Dr. Francisco Nemenzo, has time and again said: in the ups and downs of the different departments and colleges of the whole University system, PGH is the rare cluster in the system that has remained true to its mandate, and has constantly been on par with the best in areas of service and academic excellence.

Tell us what has been keeping you busy.

Right now I am the deputy director for fiscal services of UP-PGH. I was appointed November 2011, so it has been over two years now that I have been occupying this position, and this has certainly kept me busy. I am also a clinical associate professor of the Department of Ophthalmology and Visual Sciences.

Sounds like a big responsibility to be a deputy. Do you have to be a doctor to occupy this position the way other positions in a university must come from the ranks of the faculty?

The scope of my work is just PGH, not UP Manila. For the fiscal office, you do not have to be a medical doctor to occupy the position. Several years ago there was an accountant who occupied this position. It has become the practice to appoint a medical doctor from the faculty because a doctor would have some understanding of the medicine, medical equipment, and medical supplies that we have to deal with daily in our purchasing and disbursement of funds.

It must be quite a sacrifice to occupy such a position. What made you accept it? What is the fulfillment?

When the position was offered to me, most of my friends and mentors and family were very supportive, but one of my mentors told me not to accept the appointment; as this is a position, he said, for someone just starting a practice, so you don’t give up much; or it is a position for someone who is retiring, so it is a legacy work for someone on the way out of the University.  Even Director Jose Gonzales tells everyone, and he mentions in his speeches and lectures, that his deputies and coordinators are sacrificing a lot to serve UP.

There is really no attraction to the position, but in 2010 when I was offered to be coordinator for resource generation, I had to refuse outright because I did not know anything about fund raising. When this position became vacant, and it was offered to me, I felt compelled to accept it because I wanted to be supportive and positive, rather than just retreating and being negative to challenges given by the leadership.

As to fulfillment, there are a lot to do to improve the systems of the hospital, and we are working hard to make things run smoothly. We build on what was done by those before us. Our residents are trained well and are very eager to cure or diagnose the problems of their patients. But since most of our patients are indigents, our residents tend to want to shoulder the lack in financial resources of their patients, or they spend their time trying to find funds for their patients. We keep saying residents must be able to diagnose and do their work without being saddled with the financial challenges of patients, and the residents must have a place where they can point patients to where help is readily available. The process has of course been there for a long time, but I would like to think we have been able to help streamline and build on what has been there. The head nurse of the trauma ward had recently pointed out that the turnover of patients has become faster, meaning they come to PGH and are able to complete their processing and treatment a lot faster: the turn-around time has improved significantly.

Does this mean patients do not have to spend anything?

We get to absorb the bulk of Filipinos who are not covered by Philhealth. Social workers will interact with them and ask how them how social work, the hospital, and they themselves as patients can help the financial aspect of the process. We try to make the patients find in their network or resources the ability to help the healthcare system renew itself, and thankfully PGH has sponsors, and we also have a PGH Medical Foundation. The Central Bank, for example, celebrated a significant anniversary milestone, and they decided to donate an amount of money to the cancer ward to commemorate it.

PGH also gets a good part of the so-called pork barrel or PDAF of politicians.

Yes, no doubt that helps, but it could also be double edged.  We also get pressured a lot by politicians. There are two keys to be able to access those funds:  PGH has one key, but the politicians have the other key. They have to issue a guarantee letter for us to be able to release the funds for the patients they choose to release the funds to.  How do we know they are not fake patients who just asked for a letter from the office of some congressman? How do we know they will not sell the medicine outside? PGH personnel, the doctors, the nurses, the social workers, are actually the best people to assess the patient: not the politicians. The Supreme Court decision on the PDAF is a clear improvement:  it is a move away from patronage politics. We now have more control over the funds. When the funds are allocated to us, the PGH system now solely decides in the how and for whom the funds will be allocated to. It is not tied to patronage politics anymore.

You were a student here before: how would you compare UP-PGH then and UP-PGH now?

I think that it is like comparing apples and oranges. I am just guessing, but it must have been very different and difficult before, because of the budgetary challenges then. I would think funding was a bigger problem then. Now every year the budget for PGH goes up significantly, there is also increasing support from the private sector and the alumni. There is growing appreciation of what the UP-PGH is doing as an institution.

I have talked to different administrators and teachers of UP, and there is a constant theme of sadness on the subject of UP-PGH graduates who have migrated to other countries. Why so? Do you share that sadness?

Yes, of course I share in that sadness. I guess when you work in UP-PGH one realizes it is very difficult to spot people who deserve a UP-PGH education, and after getting them in the institution, the training is long and difficult.  It took a lot of resources and talent to give them the quality education and training that they got from PGH. Aside from talent and resources utilized,  in UP-PGH students are given the privilege to interact and handle patients directly, and that kind of experience is not quantifiable.

In our previous interviews, we have doctors who say UP-PGH needs to expose students to more public health subjects and issues. There are those who say it needs to have less exposure or handling  of patients and for PGH to give more emphasis on basic science studies. What is your take on these?

I would like to think students who are able to see patients are able to absorb book-learning and theory more, at a much faster rate.  A medical problem does not just remain at the level of theory. It is not just a theoretical case.  PGH produces leaders in government and influence a lot of policy, so I tend to agree that we need more public health subjects and issues in the curriculum.

Former Chancellor Ramon Arcadio had a rule that medical students, trainees, had protected time, from 12 pm to 1 pm, for example, you cannot have rounds: the medical students need to eat lunch. By 5pm, you cannot extend your lecture, no bedside rounds as they need time for studies and extracurricular activities. A former medical student also led the fight for restrictions on the number of procedures a person in training is allowed to do. Intravenous line insertion, catheter, nasal tubes, the hospital cannot compel you to do more in a day than a certain agreed upon number. I think when you said there should be less stress on exposure to patients and more on other concerns in the development of the medical student is part of that motivation to have all these rules, limits, and safeguards. But there is also the unintended consequence, I think, in that there seems to be a lower tolerance for long hours, less ability to handle stressful work. Rigor, stress, and pressure are all parts of the being a medical doctor: an eight-hour surgery is part sometimes of an emergency. When do you train for that? When you are in medical practice already? Ironically the one who led among the medical students to set limits and restrictions on what can be assigned to them by the hospital did not pursue medicine as a career. Maybe she really wasn’t for the profession.

What would be in your wish list for your specialization?

For ophthalmology, but also for UP-PGH, I wish we could do more research. You can actually earn a living, support yourself and your family, as a researcher in other countries. We should have people paid by the government to just do research. There is no funding for research, certainly not the way they do it in Singapore, for example. In the Singapore Eye Research Institute, they have medical doctors and scientists who just do research.  They do not see patients anymore, except for research. I was there for four months, but I was able to do research on glaucoma surgery, and my mentor conceptualized the research in my 2nd month. I gave the data to the statistician as I was about to end my four-month research, after a week I was asked to go back to answer some questions, and in two days she had an analysis of the data. One or two years later it was published in the Journal of Chromatography. The scientist we worked with had a way of measuring the chemical we used, wrote out the paper, and we got included in the publication.

We do not have the funding in the Philippines. All those into research who I know have a private practice on the side to support their research. There is no money in research. Research is supported by their private practice. Research for pharmaceuticals would have a different thrust. Dr. Mario Valenton was asking us when we were still students: where are your data about our incidence of angle closure and open-angle glaucoma?  We could not give him the data. Now that I am already a member of the faculty and of the administration, we still do not have the data. We need a sort of a one-stop shop where research, data, measurements, people inclined towards research can be put in this one place, and research papers will come out of this place. New knowledge and new developments will come out this way.

UP-PGH is known for producing great doctors. Aside from Dr. Ricky Luna, the great OB oncologist, who are the great doctors in your generation of UP doctors? (Laughter at the mention of the name of her husband, Dr. Ricky Luna).

Great doctors: what do you mean great? Different definitions of the word “great” would produce different answers. I have great respect for Tina Eusebio, ophthalmologist ; Michelli Gose, neurologist; Richie Yusay, urologist; Retz Gacutan, endocrinologist, Lulay Cabrera Tupas gynecologist-oncologist; Rems Elegado, dermatologist; Beth Riel, radiologist; and Ethel Tangarorang, pulmonologist. They are great for me because they are serving outside Metro Manila.  Great for me is definitely defined by the sense of service and commitment to the community, the underprivileged, serving outside the metropolitan center; I think skills after a PGH training is assumed to be way above competent. JP and Anna Leung are in Baguio and Emmanuel Dela Paz is in Bataan. I am sure I missed many more names. Bufo Gatchalian in Ormoc, Nerd Khu in Cagayan de Oro, George Repique in Cavite, Mae Aguirre-De Guzman and George Tan in Cabanatuan, Ronnie Serrano in Davao, Hazel Gazmen in Dagupan, Joy Santos-De Leon in Bulacan, Leovic Dalmacio, Ching Arejola and Orville Ocampo in Laguna, Jasmin Batara in Marawi, Dina Sazon-Carlos in Pampanga.

What has changed in you now that you are part of administration?

What previous administrators say is true: people tend to blame the sitting administration for everything, for every problem. Now that I am here, I see administrators and the staff working hard, trying to make sure the University and the hospital are up and running every day. Sometimes people complain there is no equipment, only to find out no formal request has been made for us to acquire the equipment.  What can we do in such a situation?

Do you still teach?

I still lecture on ocular pharmacology to 3rd year medical students.

What are you excited about in your field?

In glaucoma I am excited about the efforts to find ways to regenerate the optic nerve. With animals they seem to know how to do it, but they have not done it yet. March last year I was in UCLA and UC San Diego, and in San Diego one specialist said that during embryology, at a certain stage in our development in the womb, the development of the optic nerve switches off. He said they are trying to find ways to switch it back on again.

How do treatments here for eye diseases compare with treatments available outside the Philippines?

For ophthalmology, and specifically also for glaucoma, our treatments and doctors are at par with other countries. The treatments are the same. All the consultants in ophthalmology here in PGH also trained abroad.

Does training abroad help?       

It gives you a different perspective: international exchange is important. Our country has an  international presence in ophthalmology. Exchanging of ideas with different doctors from different countries is very important. We also want the Philippines in the global map in ophthalmology.

Do Filipino ophthalmologists have a strong presence globally?

Yes, definitely:  Dr. Cesar Espiritu, for example, who was with our faculty, was the very first ophthalmologist to do live cataract surgery in front of an international audience

What have you learned in your years of practice as a doctor?

I have learned that we are all the same. Human nature is the same everywhere. As an ophthalmologist, what you hear from patients, in any class or race, is they want to take care of their eyes: they value their eyesight, sometimes more than their life.

How many kids do you have and are they going to become medical doctors?

I have four kids. The eldest is now in college, in UP Manila for BS Biology. We were surprised he took a pre-med course. We thought he wanted to be a chef. My husband has two doctor-siblings, his parents are doctors. All my siblings are doctors, and their spouses are all doctors. We never encouraged our kids to become doctors: they are free to choose what they want.

Are we supposed to believe you that you did not encourage them to study medicine? (Laughter)

Well, we never say this is what is good about being a doctor, or you should be a doctor. I was already telling Ricky my husband we have to save up for the tuition fees of our eldest as culinary school is very expensive, since I thought our eldest was going to aspire to be a chef.

Your parents are not doctors, yet all of their kids became doctors. Why? How did that happen?

My parents told us to be doctors, to be our own boss. I guess we liked that idea.

Please tell us of books or authors you like read.

My choice of books are mystery novels. I am now reading Michael Palmer. Dr. Robert Ritch, my mentor, introduced him to me. Palmer is a physician and his books are described as medical thrillers. When I was in grade school I went through Nancy Drew, in high school I went through Agatha Christie, while in Singapore for research I was reading Perry Mason. I am a mystery buff. I enjoy solving problems, the way I like doing Sudoku as a way of relaxing.