First of all, DO NO HARM!

It was during the Public Health Forum 2019 when I answered the question "what is your biggest regret in medical school?" with "I was not able to document my experiences in medical school..."

So here I am taking each available moment to write about things that seem important to me.  Stories that keep me awake at night and stories that motivate me to wake up in the morning and keep trudging through tedious and challenging work.

Today was such a day.

I was originally expected to attend the ALARM course of POGS.  However, today was the HIV ENDGAME - when the Philippine Infectious Disease Society for Obstetrics and Gynecology (PIDSOG) finalizes its position statement on the interventions for the prevention of mother to child transmission of HIV infection.  There are three known modes of HIV transmission.  These include unprotected penetrative sexual intercourse, transfusion of infected blood and from an infected mother to her child.

Of these three, perinatal transmission of HIV infection is easiest to address.  There is poor uptake of condom use among males who have sex with males and freelance sex workers.  Drug rehabilitation, needle exchange and even washing of needles have proven ineffective among injecting drug users.  However, pregnancy is a condition where women generally seek consult with a physician, hopefully an obstetrician.  Prenatal check up is an opportunistic event where we can get pregnant women tested for HIV, linked to care and initiated on anti-retroviral therapy with adherence.  During pregnancy, a mother can transmit the virus to her child (1) during pregnancy, (2) during labor and delivery and (3) during breastfeeding.  Therefore, the known interventions include (1) initiation of anti-retroviral drug therapy as early as possible during pregnancy to reduce the viral load (2) to deliver these patients via elective cesarean delivery as many multi-center trials show that cesarean delivery reduce vertical transmission in untreated patients by as much as 30% and (3) avoidance of breastfeeding, especially in high risk patients who have not started anti-retroviral therapy with viral load >1,000 copies, may prevent transmission of the virus to the neonate.

We consider that public health looks at the bigger picture, that many women living with HIV might not have access to the care that she needs.  However, considering that women living with HIV are strongly advised to deliver in a facility capable of dispensing anti-retroviral drugs, referral to centers capable of doing emergency or elective cesarean section and providing alternative infant feeding modes would not be too difficult.

It is difficult to bend and compromise to policies when evidence shows that there is harm if we do nothing.  As clinicians, first of all, DO NO HARM.  We also need to remember that once we compromise, we would be changing the way other policies will be directed.

• If we allow vaginal delivery to be the standard of care for women living with HIV, health insurance might not consider HIV infection as an indication for cesarean delivery.  This will make it harder for us to facilitate delivery of these HIV-exposed neonates.
• If we allow breastfeeding to be the standard of care for all women living with HIV, it goes against the teaching that breastmilk is one of the body fluids that can transmit HIV, so why would we give something to our children that would not be 100% risk-free?  Consider the milk code and the mother-baby friendly hospital and "breastmilk is still best for babies" - there is always an exception to the rule.  Let HIV infection be that exception, so that we can find ways for the newborn to survive the first one to two years of life without spending the rest living with HIV.

In the end, patients always have a choice.  Physicians need to respect patients' autonomy, for them to decide for their own health.  Who are we to dictate how they want to deliver and how they intend to feed their baby? After all, it would be the mother who will ultimately take care of her child, whether infected with HIV or not.

Adlaw pasalamat sa dugong halad

As part of the Vicente Sotto Memorial Medical Center tribute to blood donation partners and voluntary donors at the Summit Circle on June 21, 2019, the VSMMC Department of Obstetrics and Gynecology is recognized as the only department that conducts its own voluntary bloodletting drives.  

For donating 85 blood units in 2018, the VSMMC Department of Obstetrics and Gynecology receives the Luis Flores award. 

 

With several resident physician trainees donating blood for the first time, the quarterly activity becomes an opportunity to declare selfless love to neighbor, community and country.

Healthcare Provider Engagement in Public Health thru Social Media

A few days ago, we concluded our quarterly maternal-perinatal statistics - a coordination meeting jointly organized by the VSMMC Department of Obstetrics and Gynecology and Department of Pediatrics, in coordination with the Department of Health.

In the past five years of specialists reaching out to peripheral referring hospitals and institutions, we have seen an improvement in maternal and neonatal service delivery thru the reduction of total admissions and maternal deaths in the apex hospital and the improved functionality of the DOH-retained and provincial hospitals.

Looking at the website of the Department of Health, there are several health programs from A to Z. These are programs meant to improve the health-related quality of life of the general public. Listening to the discussion among DOH health officials, there seem to be a lot of challenges with implementation of these programs, including governance, monitoring, evaluation, research and policy development.

T1. Cite challenges with implementation of public health programs.

In 2018, the AMSA-SOMA (a student organization of the Cebu Institute of Medicine) organized the Public Health Forum 2018 where medical students in Cebu were exposed to the possibility that all healthcare providers whatever their chosen field, can engage in public health - whether in research and epidemiology, health financing, policy development, specialist clinical practice, or rural health development. The following year, medical students were exposed during the Public Health Forum 2019 to the concept of private-public partnership, the role of corporate sectors in health, upcoming the universal health care, macrofinance in healthcare systems, health research and development, and the role of social media in healthcare.

T2. How can healthcare providers engage in public health?

Rosemary Thackeray observed in 2012 that social media use by public health agencies is still in the early adoption stage. Pushing the idea of "click to brick" of continuing online conversations to action plans offline, we may also consider augmenting face to face collaborations for public health programs to improve connectivity between stakeholder online. Public health programs can benefit from healthcare providers engaging with patients and stakeholders on social media.

T3. Can you cite public health programs that might benefit from social media campaigns?

When Lightning Strikes!

Expect the Unexpected

It was a weekend to meet and greet.  For 10 years, our med school classmate JP Rosales lived in the US, and for the first time since graduation we were going to meet up, and get acquainted with his children.

As soon as I landed in Manila, I realized that my bag was missing.  Hence, I couldn't meet with Jen in Quezon City.  Instead, I went home to my nieces.

I spent the afternoon chatting with my medschool bossom buddy Jenivic talking about our aim in life, our experiences and our lifestyles. We bonded over food and worried until the rains began to pour.

When boarding is supposed to be at 11:00 p.m. and yet flight gets delayed by 4 hours, with actual boarding time at 3:30 a.m. instead....

I realized I was no longer feeling well when my feet felt numb, then looking down I saw my swollen feet.

People were not complaining. Somehow I felt that people simply ACCEPTED that flights would be delayed. There's a sort of fatalistic warning that doom would pervade if we pushed for flights to proceed.  We were lucky that our flight was simply delayed.  Other flights were redirected to Clark airport. Other flights to Visayas like Bacolod and Iloilo, and even to Cebu were outright cancelled.

Then there was a group of passengers who gathered around one boarding gate, who started talking selfies. I wondered who the celebrity was.  As the delegation walked along, I realized that it was Bong Go, and where there is Bong Go, for sure there would be President Rodrigo Duterte.  True enough he was walking around, talking to passengers and sitting down for a snack.

When time finally came for us to board our plane, i asked the attendant for the reason for the 4-hour delay.  She answered "lightning alert" in Manila and runway repair in Cebu airport as cause for delay.  Soon as I found my seat, I simply fastened my seatbelt and promptly lost consciousness.

It seemed like a sign to see a rainbow after the difficult voyage from Manila to Cebu. I slept most of the drive home.  It was as soon as I reached home that I was beseeched with violent migraines with blinding pain scores of 10/10 when I was afraid I was having a hemorrhagic stroke.  I asked my brother to take my blood pressure and to massage my temples and to give me pain medications, as well as a receptacle for vomitus. A day in bed to recuperate.  Later on I will realize the meaning of spending the whole afternoon, evening and dawn at the airport.

Life is sweet!

With cloud-covered mountains, quiet higheay roads surrounded by green fields all around, Negros is a laid back town. Even the folks can't be rushed and the professionals are not competitive, but very hospitable.

Mambukal has a butterfly farm, where the attendant who hopes to be a doctor someday, tells us about the science behind taking care of butterflies, its natural history and stages of life.

The city has a lot of heritage sites that I feel sure the local government would want to showcase this in events similar to our Gabii sa Kabilin or "night of heritage"