CHILD OF THE SUN: Courage

MANILA ( MindaNews/19 Nov) — I left UPPGH (University of the Philippines-Philippine General Hospital) in 1976 after my training in surgery here. And a lot of things have happened since then. A lot of time has passed. Thirty five long years. And there were times during those years when I often looked back in anger at what UPPGH has done or more importantly has not done to the least of our brethren here in the Philippines.

Lately though, I have been coming back to UPPGH for one reason or another. This time it is to talk to the UPPGH about Emergency Medicine within the context of cooperative hospitals. Perhaps my life is coming around full circle, in much the same way that the criminal or his victim comes back to the scene of the crime or the fish swims back from the sea to the river where it was born; to spawn, and then to die.

But 35 years is a long time to hold a grudge against UPPGH. Most of you people here were not even born yet when I left this place. As a matter of fact, the Department of Emergency Medicine wasn’t even thought of then. For me, there was only the Department of Surgery and I must confess that throughout my 10 years of education and training here in UPPGH, the best time I ever had was when I was assigned as the surgeon on duty in the emergency room.

If you will indulge an old man his reminiscences, we were only 35 surgical residents then serving the entire hospital (as opposed to about 150 residents in surgery nowadays). And the residents looked at the 3 month emergency room duty as a sort of punishment one had to go through to become a surgeon. One could always tell the three poor bastards who were going through their emergency room rotations because they wore the most frazzled, put upon look and were jumpy and jittery as rats on a hot tin roof. We all knew that every time we went on duty in the emergency room, we were putting our lives on line. As a matter of fact, the first time I went on duty as a mere intern in the emergency room, I almost got killed by a drunken policeman. The ugliest thing I can recall in my life is the barrel of a snub nose .38 caliber revolver pointed at my forehead by a man with the clear intent to kill. It was a good thing I was young then and an aspiring marathoner so I knew how to run. Fast.

I remember that surgeons on duty in the emergency room then, after they endorsed their patients to the next on duty, also solemnly endorsed the official (in quotation marks) .45 caliber automatic pistol as well. That was kept in the surgeon-on-duty’s drawer. For self-defense. Only Ben G and I refused to accept this gun. Ben G was two years ahead of me in the department and he was the coolest guy in town. He never lost his self control amidst the bedlam that often happens in the ER. There was absolutely nothing that could ruffle him. He never yelled at anybody or lost his temper at the usual unruly drunks who fight, then come to the ER to have their lacerations sutured, and then fight again in the ER. He was always there, talking in a soft voice, reassuring, comforting. A pillar of strength in the ER. He was my idol until I discovered his secret when he forgot to clean up his drawer after his duty day – and I found out that he was consuming sheets and sheets of sample valium tablets during his 24 hour stint.

 

Still, I recall my emergency room duties with a lot of affection. There is something about sudden physical pain and the attendant inconvenience, distress, anxiety, sorrow, and dread of impending loss, whether personal or that of a loved one, which brings out the best or the worst in people. There is simply no in-between emotion or state of mind. But the funny thing is that one very often cannot tell which is the best, or which is the worst, in the confusion and the conundrum that is the emergency room; until very much later, perhaps when you are as old as I am and have the luxury of shifting through so many memories that may serve as reference points to your judgement.

So I guess this is what attracted me to the emergency room, and perhaps this is the reason why some of you decided to train in Emergency Medicine. Because this is really where life happens (or sometimes ends – for some people, at least).

But if we were to measure the stress level in any institution, both public and private in any community then we will have to choose the Hospital as the epicentre of all anxieties. For nowhere is the stress level in a community more acute and more heightened than in a hospital, not even the churches or the police or fire stations can match the level of physical and psychological stress and sorrow that a hospital contains in 24 hours.

And in any hospital, there is no other place that contains more acute anxiety and raw emotion than the Emergency Room of the Admitting section where the Department of Emergency reigns supreme. Here, for three years of your life in the Department, you have to look at Life in the eye and make sure that Life blinks first. For the essence of a doctor in the emergency room is to remain unflappable – or at least, look and act unflappable. And there is the trick. Because nobody among us really is unflappable. So this is where your sense of humor comes in. Because Life despises put-ons and insincerities.

But Life values Courage.

But I shall not talk about Courage. Because if you survive the three year Sadomasochistic rituals that compose your training here in PGH, I am pretty darned sure you know what Courage is all about.

Manila is the most densely populated area in the world with 43,079 inhabitants per km2. The 6th District, in which PGH practically belongs, is the most densely populated area in the most densely populated city in the world, with 68,266 bodies and souls crowded together in one square kilometer. This dwarfs the density in Calcutta India, which is only 27,774 inhabitants per km2. The total population of the Greater Manila area is about 11.6 million, this is not counting the populations of the contiguous provinces of Rizal, Bulacan and Cavite that are involved in Manila’s urbanization and who may also access UPPGH facilities for their health needs.

 

So one can imagine what kinds of mind boggling conditions and stories happen when 68,266 people cramped like rats in such a small place begin to badger, batter and butcher each other in their daily interactions. And the sad end results of Man’s inhumanity to Man eventually reach the Emergency Rooms of UPGH.

Here in the hot house of PGH training, among your patients, where you are exposed to unprocessed pain and raw emotions and reactions in the presence of the defeat, desperation and bewilderment that hover in the air in the emergency room compounded by histories of deprivation in a culture of scarcity and faced with the daily anxiety of acute need and a bleak future, your personal Genius as a doctor must take seed and perforce take root and blossom.

But without Courage, it will wither away. Very Quickly.

So instead of Courage, I shall talk of Emergency Medicine and its relevance to the rest of the country, specifically in the context of the Cooperative Health System, which I happen to represent.

Let us take an example. Suppose I am the chief resident of the Department of Emergency Medicine. I am graduating at the end of the year after three whole years of rigorous hospital training in the biggest, the most crowded, and the best university hospital in the country. My Genius has blossomed. I have the zeal, energy, competence and efficiency to treat any patients in any emergency room according to international standards. I am bursting with experience, knowledge, and psychomotor skills. I am bright eyed and bushy tailed, and ready for the world.

But is the world ready for me?

Or to be more specific: Is the Philippines, my own country, ready for me?

My answer to this question would bring me back to the point and the reason why I left UPPGH 35 years ago in anger in spite of the Department chairman’s offer of consultancy after I finished my residency in Surgery.

In my fifth and senior year of residency in Surgery, I happened to be the President of the Residents’Association, the PGHPA. I had the nerve to propose to the chairman of the Department, Dr. Recio and the PGH Director, Dr. Carreon that they allow supervised private practice for the Senior Residents of all Departments in PGH.

This really knocked their socks off! They were shocked to the bones, even if they knew that most of the senior residents were already secretly holding their private practices in and around the hospital, as this was probably what they also did during their time. But the idea, brought out in the open, really aggravated them.

I argued that a senior resident is probably in his late twenties or early thirties, usually with a wife and children and after his training stops, so does his salary (presently around 30 thousand pesos). It takes years to adequately set up a private practice to support his growing family. So what does he do in the meantime? How is he going to feed his family?

Dr. Recio, God bless his soul, after he recovered from the jolt, declared testily that the UPPGH’s role was only to train the residents, not to feed their families.

And Dr. Carreon, God bless him too, (he was Dictator’s personal physician and he suddenly fled to Australia before Martial Law ended), called me outright immoral.

To me, this reaction brought to fore the arrogance of the UPPGH training system. They think that their graduates are so brilliant, they can survive anywhere.

Well, they don’t.

And that is probably why the majority of them are found in the United States of America and some of the doctors who were my contemporaries in PGH are now serving as nurses in California.

And of those who opt to stay in the Philippines, more than 70%, are found in the greater Manila area, where the money is. There are very few of them in the provinces of the Philippines, where the need is.

They do not seem to survive very well in the provinces.

So: Can the Emergencivist survive in the Provinces?

Well. What do you think?

But isn’t this be a question you probably should have asked yourself before you went into training? And isn’t this a question your trainors should have asked themselves before they even organized the Department of Emergency Medicine in UPPGH about two decades ago?

Sure. I know the stock answer. The UPPGH is in the forefront of the Science of Medicine in the country and must keep up with the international standards of health care delivery. If they’ve got it, then by golly, we’ve got to got it too! After all, we export doctors, don’t we? And they shoot horses, don’t they?

And this is how I got into a shouting match with Dr. Florentino Herrera, who was the Dean of the UP College of Medicine in my time and who sent me and all the other interns to Bay, Laguna for a month to learn about community medicine. There I found out that every other person, especially the children, had pulmonary Tuberculosis but hardly anybody could afford the TB medications I was prescribing. So after my stint, I burst into the Dean’s office and accused him of turning me into an embarrassing luxury few of my countrymen could afford. The Dean countered by saying that the UPCM was the finest in the country and altering the curriculum would cause the Science of Medicine in the Philippines to lag behind other countries in the world. I disagreed with him and pointed out that Medicine was more an Art than a Science and as such, must pertain to people. The Dean, at that point in time, had no patience for an impertinent Intern.

This attitude about health as being mainly hospital based is unfortunate because it ignores the 95% in the community who may not need a hospital in a year’s time. However, most of the Filipinos will probably need to go to a hospital for treatment anyway, at one time or the other in their average life span of more than 60 years.

Let us face it. We will all die. But before we die, we will probably get sick. And people usually get very, very sick before they die. So chances are most of us, if not all, will need the services of an emergencivist in the hospital sooner or later.

So clearly, there is a need for Emergencivists in the provinces.

But will the Emergencivist also be an embarrassing luxury few of the Filipinos can afford?

Twenty years ago, when we first serendipitously stumbled on the concept of Cooperative Health after more than 10 years of soul searching for our relevance as health workers in the war torn areas of Mindanao, 62 out of 100 Filipinos died in the country without being brought to a hospital. Today, in spite of the supposed progress after martial law, we discover to our chagrin that now, 68 out of 100 Filipinos die without seeing a doctor or a nurse! What has our country been doing about this? What has PGH been doing about this? What have we, as doctors, been doing about this? What have you personally been doing about this? Or are you going to tell me that as a doctor, this is not your concern?

We in the UPPGH and all the other training hospitals in the country were trained to deliver health care along western lines. Western medicine focuses on the disease, the tissue, the cell, the chromosome, the DNA, the molecule, the ion. Our people apparently want us, as doctors and guardians of the health of the community, to look at health in another way.  Health is about people.  Health is about families and communities.

Whereas the present dominant world order looks at disease as a personal event with financial considerations, the Filipino looks at disease as a social event with cosmic considerations.

No wonder the graduates from UPPGH find it so hard to survive in the provinces!

Two months ago, the UP Mindanao Infirmary was host to a senior resident in Family Medicine from PGH who was assigned by the former UP Manila Chancellor to man the newly constructed University Clinic in the township of Mintal in Davao City in Mindanao. It was a month long vacation for him, practically. The campus is in a rather bucolic area and the clinic serves mostly the 1000 rather health young adult students in UP Mindanao who suffer mainly from headaches and blurred vision during exam weeks; but all around and even within the UP Mindanao campus live more than 5000 squatter families who go about their daily lives without adequate shelter, clean water, and toilets – and very often, without food.

When asked what he didn’t like about his stint, he replied that he missed his training in PGH and was afraid that his month long stay in a rural community would set back his FAMILY MEDICINE training. He did not look upon his month long stay in the middle of 5000 squatter families as an opportunity to advance his learning in FAMILY MEDICINE! He was probably looking for a trainor in the boondocks of Mindanao. And it did not occur to him that the community is the best trainor in the Philippines, bar none. Perhaps for him, the family was not a part of the community and vice-versa. There was another specialty for that, he said, the Commed. Or the Community Medicine department.

I thought this rather strange. And particularly sad.

But shouldn’t we as doctors, train with the ends of our communities in mind? Or do we really consider the health needs of our communities as irrelevant to our training as doctors?

The graduates of our hot house training programs in UPPGH look upon themselves as finished products. It seems there is no further knowledge or training that the community can offer them. Any additional training can only come from hospitals and institutions abroad – who all got what we ain’t got. And then they come back to the Philippines, if ever, with more letters added to their names. That is supposed to make them better. So they can fit our patient and our communities into the concepts of health care delivery systems they learned outside our communities – abroad.

But shouldn’t it be the other way around? Shouldn’t the doctor first try to fit himself back into the culture of the community that begat, nourished and nurtured him before he got into UPPGH to be educated and trained?

So my beef with UPPGH continues. The UPPGH is supported by the taxes of poor Juan de la Cruz who dies in the provinces without being able to access the health care UPPGH offers in Manila. There are more than 80 million of them out there in the different islands of our archipelago who do not have access to the knowledge and expertise you trained for here in the DEM, UPPGH.

This year, the PGH turned 104 years old. But never in its history of more than a hundred years did PGH ever have a systematic, functioning Placement Bureau, so her graduates can be properly placed, supported, and encouraged to practice in other areas in the Philippines where they are needed most. I do not know the cause of this oversight. But I am sure arrogance is too simple a reason for it.

Sure, as a lame gesture to the Filipino people, UPPGH has belatedly decided to do something about the situation and instituted a three year contract service for its graduates. But without a fully functioning and adequate Placement Bureau, this measure borders on the criminal because these onerous service contracts only increase the level of frustration of the graduates and inevitably facilitate their exportation – three miserable years after their graduation. Left to themselves, these fully trained, finely honed and acutely tuned medical specialists will wither away in the provinces without the adequate support of their fellow specialists and the expensive paraphernalia they require for their practice.

Not the least of their worries is the incapacity of their patients to compensate them adequately, because health is not a priority expenditure for the ordinary Filipino. He would rather spend for inessentials like his cell phone loads, gin, and cigarettes, rather than save up for his and his family members’ inevitable hospitalizations.

It was with these problems in mind that the Health Cooperative movement in the Philippines started out there in the boondocks of Mindanao, the frontiers of the Philippines, out of the desperation of a people steeped in neglect and dire want and brutalized by the spectre of war that even now visits and revisits us time and again in ever repeating vistas of death, destruction, and devastation.

So today, I have come back from Mindanao to the scene of the original crime – the great, ghastly crime of education and training for the sake of education and training themselves, and not for the sake of the people who offered their blood, sweat and tears, yes, even their very lives and limbs to train the people in UPPGH. And behind me are 21 areas in the Philippines in Luzon, Visayas and Mindanao where we have set up our Health Cooperatives. It ain’t much. But this is only the beginning. I am aware that I am planning beyond my lifetime and somewhere out there among you young people who gave me the invitation to come today, may be somebody who might be a better renegade than I am and who may want to take this little effort farther than I ever dreamed it would.

The Health Cooperative does not believe in setting up Hospitals or Health Facilities that are stand alone, like shopping malls that deliver goods and services only to those who can buy them at whatever price they are available. We believe that any system wherein the people in the community are reduced to mere passive purchasers of health instead of active participators in health provision is bound to fail, as our health care delivery system has failed miserably in the Philippines.

Health Cooperatives are owned by the communities, both health providers who are doctors and other auxiliary personnel and the health beneficiaries, the patients and their communities. Our areas of activities cover hospitals, diagnostic centers, health financing, and drug distribution; and now we are focusing acutely on Community organization, management and development. We cover 21 provinces in the Philippines and counted a consolidated asset base of about one billion 500 million pesos last year. And we are still growing. We are networked into a federation and now have come up with one software for all our operations. Of course, we are also into telemedicine, since that can only happen with the kind of network we have established.

We believe that the Filipino can only demand his basic rights, like health, if he is ready to shoulder the attendant Responsibilities that come with these Rights.

Our Health cooperatives believe that Health can and should be a fulcrum to move into the community organization, management and development that is so badly needed for us to meet our vision of adequate, affordable and appropriate health care for all, especially those in the marginalized sectors.

The MEDICAL MISSION GROUP HOSPITALS AND HEALTH SERVICES COOPERATIVE OF THE PHILIPPINES also believes that there is no such thing as Private Health. All health is Public.

UP is a national university and PGH as its teaching hospital is necessarily a Public hospital.
I am happy to be here to talk to the Department of Emergency Medicine, the youngest department in the hospital, and looking for a place to stand in the practice of its specialty in the Philippines.

Our group of Health Cooperatives is a people’s organization dedicated to the provision of health to ALL, not just those who can afford it, but most especially to those who cannot.

Of course, we realize that this is not easy to do in a financially sustainable way. We are aware that even as we have had modest successes in 21 areas in the Philippines, we also have had some spectacular failures.

But let me make it clear to everybody here in our assembly, especially to the doubters and the faint-hearted:

WE ARE NOT AFRAID TO FAIL!

We are not afraid to fail because we know we will succeed. Let it be clear to all and sundry, to the people in government and to the people in businesses engaged in health that we are willing to march into hell to dare the very devils themselves to a dance if only to provide health to all, especially to those who cannot afford to live. But the dance must have to be to our people’s music.

I come here as a representative of the MEDICAL MISSION GROUP HOSPITALS AND HEALTH SERVICES COOPERATIVE OF THE PHILIPPINES Federation to offer to UPPGH our help and cooperation in the setting up the much needed, and much delayed Placement Bureau for the students and resident graduates of their training programs, especially of the Department of Emergency Medicine.

We propose that the students and the residents run this Placement Bureau themselves; because this directly concerns their future and the future of their families, as it also concerns the lives of the Filipinos outside the greater manila area. We are ready to offer the office, computers and software to you outside the UPPGH campus.

But we require from you the openness of mind, and the honesty and humility to actually want to
learn from our people. We require a perseverance and a commitment to service that will see you through myriads of painful experiences and sacrifices. We forewarn you of the bitter taste of failure as part of your experience with us. For only those who fail the most will ever be worthy of  success.

Even as you have gone through the plethora of pain and sorrow in your years of training here in PGH, there is still that and more in your journey to finally apply your hard earned knowledge to serve the people in our country who sacrificed so much to see you through to your triumph here in PGH.

Let the Health Cooperative be the staging point of the start of your new training to come up with a program for Emergency Medicine that applies to all, everywhere in the Philippines. There will be no more trainors with kilometric letters after their names to put you through the paces. There will only be the Filipino people. And the Health Cooperative will stand by you in your efforts to come up with a  course that will be relevant and responsive to their culture and socioeconomic status.

Do not consider yourselves as Finished Products when you step out of your training programs in PGH. You would have hardly just begun.

The only time you are really finished is when you stand before a Judge somewhere and He begins to weigh what you have done or what you have not done to the least of your brethren here in your community. And if He is well pleased with you, He will be adding seven more letters to your name, right after your MD, DPBS, FPCS, FACS…..etc.

And all seven letters together will spell the word: COURAGE.

Because for poor Filipinos, it is the only thing we have.

But for Him, it is the only thing that matters. (Speech delivered at the 11th Post-Graduate Seminar for Emergency Medicine at the UPPGH on November 17. Dr.  Jose “Ting” M. Tiongco, chief executive officer of the Medical MissionGroup Hospitals and Health Services Cooperative- PhilippinesFederation, writes a column, Child of the Sun, for MindaViews, the opinion section of  MindaNews. He is author of two books, “Child of the Sun Returning” (1996) and “Surgeons Do Not Cry” (2008). The second book is available at UP bookstore,National bookstore and MindaNews)

 

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