(This speech was delivered on 28 August 2013 at the Ramon Magsaysay Building, Roxas Boulevard)
The topic of my lecture is Medicine as a Social Mission: Ensuring Health for the Poor. Much that I do not want to make this lecture a personal account, I cannot speak outside of my personal experience with the same certainty were I to use materials that I have only read or heard. Furthermore, I have already done a lot of introspection about my career and maybe by hearing myself aloud I can validate my conclusions done in silence.
So bear with me.
After I completed my postgraduate training, I had to decide what career path I should pursue. I chose a career in academic medicine so I joined the faculty staff of the Department of Medicine of my alma mater, the University of the Philippines Manila (UPM). UPM is a public university and, while it is a de facto national university, it was not until 2008 that it was, by law, recognized as such.
Being a public national university, it is heavily subsidized by tax money. In such a university, there are at least two kinds of politics. The first, often vicious and engaging, is internal. It has something to do with ascent in the academic ladder. To be more precise, it is about getting ahead of the pack. The second, benign and rarely taken seriously, is external. It has something to do with responsibility and accountability. The people who support the university with the tax money they pay to the government expect something good, a general good, to come out of the activities of the institution.
I am quite adept in dealing with the first because it is about research publications, teaching, and administration. I am not trained to respond to the second because it has never been formally part of a medical education and training. But respond I must. As a health sciences university, our responsibility and accountability to the people go beyond the scientific and state-of-the-art care of the sick. As my late revered mentor, Dr. Antonio G. Sison, used to say, “a doctor who knows only medicine does not know medicine.” Stated in a different way, but meaning essentially the same, the author of our textbook in Obstetrics and Gynecology when I was in third year medicine wrote on the fly leaf of his book, “We teach our students the kind of obstetrics which they will not practise and they practise the obstetrics we never taught them.”
These observations from two eminent physicians suggest that, while medicine and the related professions are fundamentally biosciences, their relevant practise should be guided by social consideration.
The health professions must, therefore, be viewed as partaking of the social sciences discipline. If it were not so, then, most health problems should be solvable by the application of the appropriate scientific technology. But there are numerous examples where application of medical technology alone fails to eradicate a disease of public health importance. For example, we have curative medicines for tuberculosis. Why is it that this disease is still with us in alarming number? The answer is, between the provision of free medicine and the patient taking it religiously for at least six months, are imponderables which include prosaic social factors. Ameliorating the social determinants of health and illness may in fact be the decisive factor for their successful control, more than the application of medical technology, no matter that it is of the highest efficacy.
What I would like to do is to share with you specific examples of how academic undertaking in the health profession education and training can be configured in response to social concerns as to be diametrically opposite the accepted norm.
In 1973, we were alarmed at the massive loss of our graduates to America and the gravitation of the few who remained in the country to urban medical centers. Some of us who felt that we have betrayed the people who paid for our education and, subsequently, our salary, decided to do something. Upon the initiative and leadership of the Dean of the UP College of Medicine, Dr. Florentino Herrera, Jr., a small group of faculty members was tasked to find a solution to the problem, doable within our limited material resources and political influence. The solution was to establish a School of Health Sciences (SHS) in Palo, Leyte. The school was very radical in concept. Without going into great detail, the application of the concept to the recruitment, education, training, financial support, and deployment of its students were the opposite of those practised in the traditional colleges in UPM. Just to cite a specific example, our students did not apply to us: they were elected by the community. They did not pay tuition, instead we gave them living allowances. Their progress in school required periodic endorsement by their communities.
It has now been 35 years since the SHS was established. Ninety five percent of its graduates have remained in the country. This alone proved the effectiveness of this innovative program in mitigating the loss of health professionals to other countries. The School, more than any academic unit of UPM, has been cited internationally as a good model for producing health professionals, especially in the third world. It is incomprehensible to me that despite this success there are just 2 clones of the SHS in the Philippines one-third of a century after its establishment, whereas, it should have been the main format, at least for state universities and colleges.
At about the same time that the SHS was established, we introduced in the Philippine General Hospital a parallel program, with a kindred purpose of minimizing the loss of medical specialists to the United States of America. The antecedent problem was the lack of postgraduate specialty training in the various subspecialties of medicine in our country. Those who sought such specialization had to go to the U.S.A. Since the opportunities for staying in the U.S.A. after such training are very seductive, the majority of these trainees remained in the U.S.A. upon completion of their training.
With a grant from the China Medical Board of New York, I proposed and developed a clinical fellowship program to be established in the Philippine General Hospital, to provide specialty training locally in various clinical specialty of medicine. The success of this pioneering effort provided the necessary impetus for the adoption of the program in many medical centers in the country because it proved we can do it. By this time, the overwhelming majority of our specialists are locally trained. In fact, an unintended consequence is that we are producing more specialists than what is actually needed.
The third program that addresses the social mission of medicine in education and training has to do with the fractured relationship of clinical medicine and public health. Traditionally, clinical medicine is concerned with the care of a particular sick patient. A clinician, a professional practising clinical medicine perforce, view medicine in terms of a sick individual. Public health, on the other hand, is concerned with the health of a community or a population. The public health practitioner consequently view them in terms of a faceless mass of people where an individual is merely one of the many. This particular dichotomy between clinical medicine and public health is viewed as a schism. This divide weakens the effort of solving major health problems, and lessens the opportunity for cooperation between the two otherwise complimentary professions. The Rockefeller Foundation felt it was their fault that this situation came to pass because they were the principal sponsor of most major public health schools and colleges established around the world after World War II. The Rockefeller Foundation, therefore, felt it was their duty to correct the situation. In order to bridge the chasm brought about by the schism, they introduced a program called “Clinical Epidemiology” with the hope that clinical medicine and public health will come together again. This new discipline enables the clinician to deal with institutional problems as well as the health of a community or population without losing the perspective of one who treats an individual patient. Clinicians trained in this discipline become well-versed in design, measurement and evaluation. Consequently, they are competent in evaluating the evidence that supports or disproves claims about particular intervention in clinical practise as well as public health measures. Additionally, the clinical epidemiologist is conversant with clinical, policy, health outcome, comparative effectiveness, and program researches.
In 1984, the Rockefeller Foundation invited me to establish a Clinical Epidemiology Unit (CEU) in UPM. Within a short span of time, we were able to recruit a critical mass of very talented and dedicated young faculty members to join the new unit. This first batch of recruits now hold leadership positions in health institutions both here and aboard including the World Health Organization.
More importantly, the CEU has upgraded the quality of medical research, first in UPM and eventually nationwide. Presently, the CEU which has been upgraded into both a Department and an Institute, functions as a national resource of government and private institutions. The relevance of such a unit in the health field is attested to by the establishment of similar units in the leading universities in the country principally thru the initiative and nurturing of the UPM CEU. It can be claimed that the enhanced quality of health researches in the country is largely attributable to these units.
Constantly aware of the social responsibility of the national university to the people, we have endowed even our research activities with social dimension.
In 1988, under a new presidency, UP undertook a major reorganization of UP Manila. As a member of the reorganization committee, I batted for the establishment of a central research facility. To highlight our social commitment even into the field of biomedical research we named the new unit Socio-Biomedical Research Institute (ISBMR). The name is not merely symbolic. It was a deliberate choice to underline the equal importance we attach to social science research vis-a-vis biomedical research in the health sector.
During the term of my successor as Chancellor of UPM, the ISBMR was transformed by law into the National Institutes of Health (NIH). It is now a national research facility with a big mandate.
Within the NIH are institutes and study groups dealing with social issues; for example, the institutes for aging, newborn errors of metabolism, health policy, health human resource, health care financing and a few others. The Universal Health Care Study Group (UHCGS) is one of the study groups within the NIH.
Thus, while fundamental studies in medical science continue to be a major activity of the university, this is enriched by social studies that enhance the utility of the scientific output of the biomedical researches.
In 1988, when Dr. Jose Abueva was appointed president of UP, he characterized the university as “an agent for social transformation.” This became the theme of his presidency. Sometime in 2008, Republic Act No. 9500 transformed UP into a National University. Under Section 8 of this new University Charter, the university has been committed “to serve the Filipino nation by relating its activities to the needs of the Filipino people and their aspirations for social progress and transformation.”
In 2008, during the centennial year celebration of UP, former Health Secretary, Dr. Alberto G. Romualdez, Jr. and myself, delivered back to back lectures on the State of the Nation’s Health and UP’s Fulfilment of Its Vision and Mission, respectively. Out of the long two-year preparation for these lectures, done with the help of many colleagues within and outside the University, was born the idea of Universal Health Care (UHC).
UHC is a response to the most glaring problem in our health care system, which is inequity. Inequity is manifested in the unequal access to health care and services as well as the lopsided consumption of health goods both of which favour the rich over the poor. Simply put, there is little to none for the 60% poor but overflowing to the richest 10%.
In order to push the necessary advocacy for UHC, we organized a study group called Universal Health Care Study Group (UHCSG). Its original and only objective at its inception was to bring the issue of UHC to the consciousness of the public in order to stimulate a national debate.
Among the numerous fora organized and participated in by the UHCSG were the public meetings attended by the presidentiables running in the 2010 presidential elections. As luck or fate would have it, the elected President, His Excellency Benigno Simeon Aquino III, adopted the concept of UHC as his administration’s policy on health, renamed “Kalusugan Pangkahalatan” or KP. KP targets, among others, comprehensive health care for the poorest 60% of the population by 2016, which care is characterized by “No out-of-pocket payment”.
It is with wide open eyes that we push for UHC as the solution to the prevailing inequity in health. We have never imagined our advocacy as a walk in the park. After all, it took Germany 105 years to cover 88% of its population and Great Britain 45 years to fully establish the National Health System. Not even the mighty United States of America, which is spending 17% of its gross domestic product on health has achieved UHC. It is not mainly the wealth of a nation that determines whether it will have a UHC system or not. Cuba, which is no better than us in terms of wealth, has a remarkable UHC.
Rather, it is the will of the people and their leaders, staying the course, no matter what, that will determine whether a UHC can be put in place. We have started it. We better finish it.
In advocating for UHC, we or I have relied heavily on our experience in pushing for universal vaccination of newborns against hepatitis B. It is worthwhile to relive this experience for the richness of the lessons learned in the area of advocacy.
In the late 70s, bothered by the extremely high rate of primary cancer of the liver in the population of middle age to senior years, we embarked on a comprehensive study of liver cancer, including its probable cause(s). From the studies emerged the primacy of chronic infections with a virus called Hepatitis B as the single most important cause of liver cancer in the Philippines. We shifted our study to Hepatitis B because it is obvious that if this infection can be prevented, then liver cancer can also be prevented. Incidentally, there is no cure for primary liver cancer in that time and in this time.
We then did extensive studies on Hepatitis B which included prevalence, incidence attack rate, risk groups, mode of transmission, outcome of infection as well as its role in other liver diseases aside from cancer.
The results of these studies clearly pointed to the type of Hepatitis B transmission that has to be interdicted if we are to prevent and, eventually, eradicate primary liver cancer as well as other non-cancer, Hepatitis B-related chronic liver diseases. Preventing mother- child transmission of Hepatitis B via newborn immunization is the best approach. An effective anti-Hepatitis B vaccine was already available at the time. It needed only to be given to newborns, initially within 24 hours after birth, to be repeated two more times at monthly intervals for a total of three doses. But the program needed to carry out universal vaccination of newborns must surmount very formidable obstacles. Some of the megaproblems are the following:
1. In the face of a very expensive vaccine at the time, about U.S. $50, to be given three times per child, how will we ensure vaccine sufficiency?
2. Assuming we have vaccine sufficiency, how are we going to deliver vaccination to 1.8 million to 2 million newborns yearly when most of them are delivered outside medically supervised birthing facilities?
3. How adequate is the infrastructure of the Department of Health to enable delivery of vaccination within a 24-hour period after the need has arisen?
4. How do you monitor such a program?
Clearly, under the conditions obtaining at the time where vaccine sufficiency is just a dream, universal vaccination is not feasible. An alternative program is targeting only extremely high risks infants for vaccination. These are offspring of highly infectious mothers since it is the mother who infects the newborn. The problem, then, is how to identify these highly infectious from the non-infectious mothers when parturients number two million per year distributed over hundreds of islands.
We grappled with the problem by developing a simple technology that can be administered in the field by a trained non-medical personnel to identify high risk mother and child.
Meanwhile, anticipating universal vaccination, should the cost of the vaccine comes down, we worked for the introduction into the country of affordable but high quality vaccines. In this effort, the Liver Study Group of UP Manila which organized for the Hepatitis B project, performed the following tasks:
1. Broker for potential supplier to the Department of Health (DOH) willing to offer concessional price;
2. Explored commercial partnership between DOH (government) and private manufacturers for the local production of vaccines. I think this is one of the earliest example of PPP (public-private-partnership);
3. Requested the Department of Finance to change tax computation on imported vaccine based on landed cost rather than home consumption value; and,
4. Processed the blood serum source of the vaccine from locally collected blood in the Research Institute of Tropical Medicine and, by prior arrangement, ship them to a partner country for final processing into vaccines.
In the meantime we furnished the Department of Health a cost sensitivity analysis at which cost of the vaccine, a shift from selective vaccination to universal vaccination will have a better cost-effectiveness outcome. At that time the identified threshold cost was ₱0.85 (centavos) per dose of the vaccine.
When the price of the vaccine dropped even below this threshold amount, we urged the Department of Health to shift to universal vaccination. Considering all the prevailing variables we prepared for the Department a timetable beginning in the year 1992.
All these activities are not “medical” in nature. The question we asked ourselves then was, at what point does the researcher’s responsibility stop? Surely publishing the research outcome in a refereed journal is enough both for the researcher and the funding institution. We thought otherwise.
Finally when universal newborn vaccination against hepatitis was policy, there was the question of sustainability. At the start of the program, Hepatitis B immunization was naturally included in the Expanded Program of Immunization or EPI. EPI has a global budget. Hepatitis B was lost in a long list of older ‘must’ vaccines. Since the money for all the required immunogens was not always enough oftentimes, there was none left for Hepatitis B. It will take more than 20 years of continuing advocacy and the sympathetic support of some legislators to finally secure a budget item for hepatitis B vaccination.
The lessons learned in hepatitis B advocacy will surely enhance our efforts in pushing for universal health care.

Medicine as a social mission is a tautology. However, in the pursuit of academic excellence, the social context of medicine that makes it relevant is often lost. Stating the obvious is not out of order.
Let me end with a quote from National Scientist Gelia T. Castillo who, in two sentences, convey what I have been trying to communicate in the last 30 minutes, quote, “I have always believed that when the best of science and scientists are devoted to the problems of those who have less in life, that is equity and ethics at its best. If science is to serve a human purpose what better human purpose is there?”
Thank you and good day.
