|Dr. Carmel Mathilda Ladeza Graduation Speech
When I was first asked to be keynote speaker for this very important event, the first reaction was to cringe in embarrassment. Second, third, and fourth was still to cringe in embarrassment, because really, I donât think I have done anything special with my career as a doctor to deserve this honor. I have not specialized; I have not even finished my MPH degree, for crying out loud! My claim to greatness, such as it is, is that I survived for so many years in the jungle. But then again, this is not rare; the country has thousands of rural physicians.
But, in the 24 years that I have known him, I have never really learned how to say no to Dr. Cristobal. I donât think I will start now.
SERVICE, in whatever capacity.
My parents, by their actions if not their words, have taught me and my siblings at an early age that we are all put in this world to be of use to others. My career in public health might have started right after college, but I think the disposition was embedded in my DNA, and it was nurtured by the example of my parents. My family is not well-off, there are 7 of us, I was 3rd. My father was a government employee; my mother had a small pharmacy to augment the family income. As children, we were expected to contribute to the family economy: the eldest was in charge with running the household, the second with running of our store. I took it upon myself to be in charge of my younger siblings, especially in the area of personal hygiene, specifically before bedtime ablutions. My 10-year-old self decided that this is the area where I can help my mom.
Thus, my very first health campaign was conceptualized and implemented. The goal was to get my 4 younger siblings to brush their teeth and take bath right after dinner. The strategy was to establish a fun after-dinner activity, an exclusive, invitations-only night club for kids where gleaming white teeth and squeaky clean hair and skin are requirements for admission. Dress code was strict: pajamas and nighties only. We sang, we danced (I choreographed, imagine that!), we put on puppet shows, story-telling sessions, it was loads of fun, and it ran on for a couple of years. Like any self-respecting health implementer, I gave the health campaign a catchy name: we called it Pajama Jam!!!!
The strategy is a marriage between facilitate and manipulate, which i will call facipulate in later years.
My inspiration was Mark Twainâs Tom Sawyer. I am sorry, my dear millennial graduates to reference an American classic, I am just showing my age, but the story went this way: Tom Sawyer, a rascal of a kid, was punished by his aunt because he played hooky at school. He was told to paint their fence. So while his friends were playing, Tom went about his job very seriously. Soon his friends noticed, started to convince him to stop working and play with them. Tom purposely did not mind them, made a great show of concentrating on his job. He told them its delicate work, not to be entrusted to just anyone. Of course, because people in general, and children in particular, being contrary creatures, everyone wanted to try his hand at painting fences. In the end, the fence job was done, with outsourced laborers who bartered various treasures and toys in exchange for a chance to paint!
That kid club became my prototype for health campaigns. Look for health gaps; look for ways things could improve. Public health, for me, means influencing a group of people to behave in a certain manner, with a health outcome in mind.
I guess what it all taught us is that everyone is called to serve, in whatever capacity we can, with whatever talent we have.
So, the question is how does this apply you as new graduates? While I am here to talk to you about my experience as an MHO, this is not to convince to take the same path I did. While we are all called to service, it is up to us in what manner we can serve others best.
Which, brings us to the next item on my list:
Now that Iâm grown up, what do I really want to be?
A number of people have expressed surprise that I have spent all this time as a rural physician. Sometimes, in admiration, other times, in disdain. I have always believed that I deserve neither. My work, my career choice is an expression of who I am, who I think God wants me to be, and so deserve neither praise nor scorn. Itâs like praising a bird because it can fly, praising a fish for how well it breathes underwater, or praising a frog because it can croak. The bird, the fish and the frog has nothing to do with what their nature is; same is true for me and my work.
I was once asked by a first year medical student for tips on how to love working in rural community. She is a scholar, expected to payback her scholarship with service in the community. I didnât quite know what to tell her. Choosing a career is a lot like looking for Mr. Right and One True Love. And just like Mr Right and One True Love, career options, especially those leaning towards public health are often either romanticised or looked down on. In truth, public health like any career paths, have its advantages and disadvantages. Well, actually, there are more disadvantages mainly on the financial aspect. But when one is called to it, one should consider what it entails before committing fully to it.
Actually, we get a lot of PF in public health. People may not pay us in money but still we have a lot of PF:
1. Professional fruit
2. Professional fowl
3. Professional fish
4. Professional flowers, especially if youâre single
The one thing I Find amazing with what I do, is that is that I am allowed to do what Iâve always wanted to do all my life. I am humbled, and truly grateful because I know not everyone is as blessed.
I only got to this point after a few years in Tampilisan. You see, things changed when I married and had children. While my husband and I were okay with living the life in the barrio, I started questioning if it was fair for my children if I deprived them of the advantages city life had to offer, in terms of education, exposure to the larger world, and so on. Then, the ambush of the bus I was on, happened. It made me question even more if I was being selfish in endangering my life, and in effect theirs, by being so pigheaded about staying in the community. So I enrolled them in a school here in Zamboanga. The eldest was 9, the younger 6. It was a miserable time for all of us. They were okay living here with their Lola, but I guess were too young to be away from their parents. Me, I was just dying from guilt. So I entertained thoughts of going into residency, just to be near them, but just thinking about it made me miserable too. At around this time, the US visa center sent us a notice that my application for the whole family to migrate in the US is now current. Suddenly, leaving Tampilisan became a real option. A lot of people urged us to give it a try, for the sake the children. But the people who really knew me, allowed me a lot of space to decide, knowing how difficult was for me. What I came up was that, in many instances in my life, I notice a pattern: I was only truly alive when I do community work.
In the end, I decided that I can only be a good wife and mother if I was happy with myself and what I do. So I took my kids back home, enrolled them in the local public school where, im happy to report, they are doing very well.
Having made this decision, I was reminded of the talk I had with Fr. Bill Kreutz, founder of the Jesuit Volunteers Philippines, a group I am a part of, and co-founder of this medical school, who was also instrumental in getting me into medical school. We were talking about the schoolâs mission which was to provide doctors in western Mindanao. Maybe he sensed my reservations on getting stuck in the boondocks forever, because he told me, âI do not expect you to stay there forever. You will get married and your husbandâs job might take you away from the community. You will have kids and you will look for good schools for them. What weâre asking you is to stay there for a while, help out while you can. âFr Bill, I hope I made you proud. Not only did I manage to get someone to marry me, have kids by me, I even managed to get them to stay in the community with me!!
A number of people were aghast at my decision. One went on to say, âNa, keda ya gat sila bisaya!â a comment I found offensive on so many levels. One, bisaya man ko. Two, bisaya man akong bana! Whyever would our kids not speak bisaya???? And I guess my kids caught on with this view, that speaking Cebuano is less than acceptable in the city because when I told them to pack up for a trip somewhere to meet up with their cousins, one kid asked, âMag English English na pod ta mama?â. So I had to tell them, and show them, the same thing I told one medical student who was feeling anxious about integrating in the community when he does not know the dialect.
If you speak the truth, and speak it with love and kindness, it does not really matter what language you speak it in. SO, BISAYA PA MORE!
Me, I am completely convinced that at this moment, I am where God wants me to be, doing what he intends for me to do; so completely that think it borders on the delusional. There are others who look down on generalists, it really doesnât bother me. People are meant to do different things. I remember I once brought my mother to a specialist who I have worked with during internship. She asked what I was doing, and I told her proudly im still in my bukid, she said with dismay: hah!!! Uy,magtraining ka na, napapag-iwanan ka na ng mga batchmates mo!!! I knew she meant well, I also knew she really didnât know me. I just laughed it off, while my delusional mind said, âMas magaling ka pa sa Diyos?â
Oh, ayan, dalawa na ang paki usap ko. First, commit to service. Second, discern in what capacity your God wants you to serve. Internship is a good time to do this. You just came from intense immersion in the community, now will be exposed more in the hospital setting, with more responsibilities than when you were clerks, be aware that you must make a choice soon. Listen to your heart, and if you have let your god inside your heart, He will speak to you from there.
Do not be afraid to fail. Most successes were results of a lot of failures. Failures also have their uses.
So Louise, no need to feel bad if your research suggests that our intervention to prevent teenage pregnancy results to increase instead of decrease in the studentsâ risk behavoir. I have allocated funds to roll out the intervention, this year, but when I learned that the intervention did not show the results we wanted, I decided to unfund it. I am thankful that because of your research good money will not be put to waste.
When I was a newbie MHO the first major challenge was getting correct data from my subordinates. Health workers are so afraid of the backlash from DOH when they fall short of the DOH-set standards. It doesnât matter how many times I tell them that as devolved agency, thereâs really not much that the DOH can do to us.
Truth of the matter is that the health workers from the preventive sector are caught in middle of the contradicting government policies. Target for fully immunized children, for example, are pegged at 95% of the below 1 year old population. The basis for the computation for the target is the projected population from NSO, before it became PSA. For Tampilisan, in 2017, we were expected to immunize 700 children. But if you looked at our data, our livebirth ranges from 300 to 450 annually, in the last 5 years. Where were we supposed to get the missing 250- 400 children?
I used to wonder why our political leaders would not help us when we complain about these impossible targets. Turns out, that the Internal Revenue Allotment, or the budget that is given to Local Government Units, are dependent on population. The bigger the population, the bigger the budget. So governors, mayors, and barangay captains are not about to complain! Who wants lower budget? In not so many words, we were told to suck it up!!
Because health workers are afraid of being thought derelict of their duties, some would pad their data.
My take on the issue is this: we are compounding the problem if we allow and add on to misguided policies. DOH will not know they are working their field workers to exhaustion unnecessarily, the countryâs economic policy makers will not know that they have to rethink the process of allotment to LGUs. This is the reason why I take with a grain of salt any publication on Philippine health data. The data came from us field workers, I know twisted it can get.
It took me years to convince my subordinates that there is no need to cheat. As long as they did their job, and did it well, I will take their backlash for them. I am proud of our 65% accomplishment in immunization, because truth be told, thatâs actually 100%. While others might look at our figures and think our health facilities have failed, we know itâs a policy failure. It is my hope that the data we present now will be enough of an eyesore to warrant policy change.
Next, do not expect recognition! This is especially true in public health. A lot of times it can seem like a thankless job. I get my satisfaction comes from getting good health outcomes. As girl implementer of PAJAMA JAM, my satisfaction was knowing I have eased some of my motherâs burden, and looking at my siblingsâ pearly whites, that come to think of it, they never thanked me for.
Do not be afraid to innovate, to be different, to do things differently. The first major change I did in the RHU was to implement facility based delivery, a good 10 years ahead of DOH and PHILHEALTH. At the time other MHOs tried to dissuade me, saying it was too much âhasolâ. DOH albeit unwittingly, sabotaged my efforts by training more hilots, and giving them hilot kits to aid them in their home deliveries. Ten years later, when they started talking about BEMONc, Tampilisan was on its way to 85% accomplishment. When they monitored our health facility, they would not believe our data because we did not have DOH-required Municipal Ordinance requiring all births to be delivered at the health facility on pains of penalty. Itâs really very simple for me: give them consistent good service, people will submit. Tampilisan RHU was one of, if not the first RHU in the region to be Philhealth accredited birthing facility.
In later years, we would lose the accreditation for a time when DOH decided to standardize accreditation and licensing, and we scrambled to comply with the requirements.
Learn to make decisions. Diagnosis might be the key in the hospital setting, in low resource communities, the premium is much higher for decisions rather than diagnosis.
So, what are the tools to survive the jungle that is public health?
1. Thick skin! With due respect to all politicians in the audience, but if you asked public health workers what they think is their biggest challenge in terms of their work, I bet you more than 90% of them would answer, their politician bosses. The local code of the Philippines has put us government health workers in an awkward position. MHOs are tasked with taking care of the health of the population, and we are supervised by mayors, who are most of the time, unaware of the health issues in the area. At the same time Health worker wages in low income municipalities would be higher than their local counterparts. An MHOâs salary would most of time be higher than the mayorâs, which adds more to the awkward factor. One time I got so tired of my boss harping again and again about the fact that my salary is higher than his, so I told him, Sir, 10 years kong pinag-aralan ang pagiging doctor ko. Ang mayor able to read and write lang ang requirement. Kaya siguro ganyan ang diperensya ng sahod natin.
2. Arrange for someone to have your back! You will be alone when you go to serve your community, sometimes in a hostile environment. It is crucial to have at the ready a reliable support group, whether for professional or personal matters. Family, classmates, friends, pets! You will need them. This is why I fully support my students when I notice them collecting pets: there is a dog, si liit, there were cats, there were at least 4 turtles, at least a dozen chicken although hindi ko na alam if they pets or adobo. Me, I have my garden. Plants may not be able to commiserate with my misery of the moment but they are very good listeners.
3. Learn to pace yourself. Be passionate about your causes, but learn to reserve some of yourself to yourself. As doctors, we are privy to all sorts of grief. Doctors in the community, however, have front row seats to the sordid details of our patientsâ grief.
In the hospital we might struggle in announcing the death of a patient to his family. In the community, on top of the bad news that we have to deliver, by knowing the family intimately, we automatically share the burden of their other difficulties. In the hospital we would perhaps cry over a little girl who was sexually abused. In Tampilisan I examined a girl who was raped by a neighbour while she was washing the laundry at the river. . Then I heard about the relatives of the rape suspect trying to sell a property to raise money for an out of court settlement, then heard the case has been settled. Then later, you would see the rape suspect and the father of the girl at the videokehan, celebrating the settlement with a drinking spree, while the rape victim was back to washing clothes in the river. It can make you angry, it can make want to hate the world for being so unfair, yet you pull yourself together, not break down and be a mess. Because the next day, you have to face the 80+ patients who need a doctor who is not a mess. Also because you still have to go home to 3 children who need their mother not to be a mess. Husbands and wives, they belong to the group who have your back, with them, yes you can be a mess.
20 years ago, I sat with a group of 25 others in the same seats youâre sitting on right now. I remember the mix of feelings: first and foremost, relief that finally weâre done with med school! Next, unbelief that we really are done with med school. We were excited, the possibilities seemed endless, there was dread about the internship, and the medical boards after that. I am sure you will do us proud, in whatever fields you decide to go into. Iâm sure you will all be bigshots in your chosen fields. I will just ask you, no matter how big a shot you are, always remember the people who took you in as family in your communities. And for those of you who will choose the same path I took, I welcome you and congratulate you. Because, while public health may not be state of the art practice of medicine, it will always, always be state of the art practice of compassion.