Solving Public Health through Public Health

Ramon Lorenzo Luis R. Guinto

September 27, 2010
For years, we have been pondering on why we are unable to solve the problems facing the health of the
Filipinos, some of which have already conquered by several fellow developing countries. Today, a socalled triple burden of disease is endangering the health of future generation of Filipinos. The same
infectious diseases that afflicted us 50 years ago still plague our provinces and now even our cities.
Today, new dietary habits and vices have led to astronomical rise in chronic lifestyle diseases such as
diabetes and hypertension. On the other hand, the third and newest group of diseases comprises those
that are brought about by rapid globalization; now, the threat of pandemics has become unavoidable,
and perhaps exacerbated by anthropogenic global environmental change.
Today, six out of 10 Pinoys who get sick still die without seeing a doctor. Furthermore, at a global scale,
the Philippines is embarrassingly lagging in terms of attaining the Millennium Development Goals, in
cutting down maternal mortality for example. Despite reform efforts in the health system, our approach
has generally been business as usual, keeping for long interventions that were originally conceived
before as temporary band-aid solutions (such as the Doctors to the Barrio program), and giving little
attention on health promotion and action on the broader social and environmental determinants of
health.
We have placed so much emphasis on the curative, the biomedical, absorbed by the idea that we just
need more medical doctors and nurses and hi-tech diagnostics and cheaper medicines in order to solve
the health gap. I am not saying that we reduce our attention on these areas many Filipinos are still in
dire want of access to these life-saving technologies and infrastructure. However, what we also need
today to solve our chronic public health challenges is to add more public health to our approach.
A Public Health School in the Philippines
The Philippines is among the fortunate countries to have at least one school of public health, not to
mention one of the first in the world. Internationally, the origins of public health as a discipline can be
traced back to the field of tropical medicine, when colonizer countries such as Britain and Belgium, in
order to prevent disease among their troops, saw the need to study the infectious diseases inflicting
their colonies in the tropics.
Unfortunately, our Spanish colonizers did not give too much attention on improving our sewers and
providing nutrition to both the Spaniards and the indios; it was the Americans who brought the tradition
of public health, along with basic public education, to Philippine shores. One of their shining legacies in
public health is the creation of the School of Sanitation and Public Health in 1927, now known as the
College of Public Health of the University of the Philippines (UP-CPH).
Today, UP-CPH remains the lone school of public health in the Philippines. Supposedly, UP-CPH is ahead
of most public health schools in the world as it is one of the few that offers an undergraduate degree in
public health, which started as a Bachelor of Science in Hygiene (now Public Health). Indeed, this is a
great feat, because, in contrast, in most countries, a degree in medicine is one of the pre-requisites to
get accepted in a Master in Public Health program. This practice was countered though by Dr. Paulo
Buss, President of the Oswaldo Cruz Foundation, Brazils national institute of health, in one article about
Brazilian undergraduate public health education:

Much of what is taught in other health-based courses (medicine, for instance, is a pre-requisite to study
public health in several countries) is not necessarily of great use for someone intending to pursue a
career in this field. In low-income countries, one can argue there is no point of investing in training
doctors when they do not need such advanced medical skills to be public health practitioners. It certainly
would make more sense to prepare public health workers at technical or professional level in
undergraduate courses.
However, despite its pioneering work in undergraduate public health education, UP-CPH seems to
produce more medical doctors than public health officers. I dont have the exact numbers but it seems
that a lot of its graduates transfers to the adjacent building the College of Medicine and become
clinical specialists eventually. There is nothing wrong about being a clinician they are essential in the
health care system just like a public health worker but with this trend, the mandate of UP-CPH, which
is to be a leader in health promotion and disease prevention rather than just provide specialized cure to
the already sick, is not fully realized.
Lessons from Brazil and Bangladesh
As I have mentioned, UP-CPH has done pioneering work as one of the first schools of public health in the
world, but it can still learn some lessons from its younger siblings from other developing countries. One
article in the WHO Bulletin featured six unique public schools that had striven to innovate in public
health education and research, such as the Sergio Arouca National School of Public Health in Brazil. The
school designed a relevant public health course in each of Brazils 27 states, eventually giving birth to 39
more schools of higher public health education. This should also be the aim of UP-CPH to go forth and
multiply.
Today, Brazil has 0.97 public health officers for every 1000 inhabitants, a ratio even better than that for
doctors, and is one of the healthiest developing countries in the world. Brazil is examining the
possibility of setting up an undergraduate public health course, says Dr. Buss. UP-CPH has a rich
experience in undergraduate public health education, placing it in the best position to share its example
to the world. Therefore, the College can engage in partnerships with other developing countries such
as Brazil an excellent example of the so-called South-South exchange.
Another example is the James P. Grant School of Public Health in BRAC University in Bangladesh. This
six-year-old institution named after UNICEFs former executive director who launched the Child
Revolution program that improved the health of children in Africa and other developing regions. The
School is unique in many aspects first, it was established by BRAC, the worlds largest development
nongovernmental organization. Moreover, despite being a young school located in one of the poorest
and most populated countries in the world, it has established strong collaboration with prestigious
public health schools in the developed world such as Johns Hopkins and Columbia. Finally, in contrast to
policy- or laboratory-oriented public health curricula elsewhere, their unique curriculum allows students
to spend half of their time in various rural communities in Bangladesh. Since the school was founded in
2004, the whole of Bangladesh has served as a social laboratory to MPH students from more than 20
countries.
Some Doable Proposals
I hope to see the day that UP Manila, the mother institution of UP-CPH, will be led by someone from
the College of Public Health, or someone who has a strong sense of public health leadership,
regardless of health profession. For the past four decades of UP Manila as an autonomous university,

the chancellorship has been held by a medical doctor, not to mention a clinical specialist. I am just
suggesting that maybe, a public health leader in the university can shift our collective biomedical
orientation into a paradigm that champions human health on a grander scale, looking not just at
individuals but also at entire populations.
After learning from some fellow UP-CPH undergraduate students that a lot of their subjects focuses on
microbiology, parasitology, anatomy, and histology, it can be said that the present UP-CPH curriculum
places more emphasis in the biological dimension of disease and indeed prepares students for clinical
medicine. I am not saying that these subjects are unimportant, but I believe that there should be a
strong balance between the biomedical and social. Moreover, perhaps it is time to reassess the purpose
of such a curriculum do we want to train focused medical technologists or holistic public health
practitioners? Maybe it is time to teach less of biomedicine and more of the social, political, cultural,
economic, and environmental determinants of health to our public health undergrads. UP-CPH may
also explore in offering various tracks even in the undergraduate level such as a Health Policy, Medical
Technology, or Environmental Health track, even a Pre-Medicine track, so it can cater to students
coming from a wide range of interests and backgrounds.
The College must also partner with its neighbor, ally, and apparently, recipient of its graduates the
College of Medicine in establishing an MD-MPH program, which is not a new concept in most schools
of public health abroad. In doing so, we win back the clinicians to the field of public health, maximizing
their technical knowledge of clinical specialties in influencing policy and initiating population-based
programs. Moreover, we will also be able to recruit outstanding students who initially planned to
become the typical physician they know of and lure them into public health. If such combined degree
exists today, I would have been one of its students.
UP-CPH must also be lauded for joining UP Manilas Community Health and Development Program in
San Juan, Batangas. Since 2008, the College has been sending its senior students to San Juan for six
weeks. The students conduct community diagnosis and implement projects on nutrition, environmental
health, livelihood, and many other aspects. Community-based activities should be further enhanced and
expanded so that public health undergrads gain the necessary skills for educating and mobilizing people
as well as influence policies and transform institutions. Moreover, since we want our public health
students to be more exposed to social realities, other avenues for experiential learning at all levels
laboratory, town hall, community, DOH, Congress, Malacanang, even WHO should be established.
We are blessed that the Western Pacific Regional Office is just two blocks away; UP-CPH must maximize
this opportunity for student exposure to health governance in regional and global levels.
The Public Health Managers program is a great feat for UP-CPH. Thus, the College must work hard in
assisting DOH expand this one-of-a-kind program. Moreover, the College must lobby in Congress for a
bill that will make public health managers an essential and mandatory part of the Philippine health
care system. This will lessen our demand for physicians who also perform public health functions in the
local government unit.
But how can we push DOH to do so if UP-CPH can only produce around 70 students yearly, with most of
them entering medicine after graduation? UP-CPH should expand its undergraduate degree in public
health, by adding more slots, or by starting new programs in other constituent universities of UP (I
understand there is a similar program in UP Visayas), or even by encouraging the founding of new
schools of public health, just like what the Brazilians did. UP-CPH must exude visionary and creative
leadership in achieving these goals.

Moreover, even if a degree in public health is an excellent stepping stone to medicine, the College must
make extra effort in searching for applicants who have the desire and potential to truly become public
health officers, not clinicians. The College must work double time in introducing public health to high
school students seeking to apply in the university.
I am sure the next question is: How about the faculty? We have dearth of practitioners with Masters or
Doctorates. The solution is to invite real practitioners of public health those who work with
communities, in NGOs, in DOH or in PhilHealth to teach from experience. Invite faculty members
from other colleges and departments School of Economics, College of Business Administration,
Department of Political Science, College of Social Work, even the School of Environmental Science in UP
Los Banos to teach the different dimensions of society that greatly affect public health. They will
enrich the curriculum, making the study of public health less bookish and theoretical and more real and
relevant. Eventually, as more students finish public health and pursue advanced studies, we will have
more educators of public health in our new programs and institutions.
UP-CPH must exert extra effort in popularizing public health, by tapping the media and launching
national campaigns. In the US, the Association of Schools of Public Health already started a campaign
called This is Public Health, aiming to make the public aware of the inevitable importance of public
health in their lives. Ironically, even in countries with strong public health education, people do not
recognize the value of public health practitioners, since they are all fascinated with doctors and nurses
only. The Philippines is not alone in this predicament, and thus, initiatives to publicize public health
like the ASPHs are necessary. We can never run out of ideas given how creative and innovative Filipinos
are.
Ultimately, to support all the recommendations aforementioned, the College, especially its faculty and
alumni, should also lead in professionalizing the practice of public health. The Medical Act defines
what constitutes the practice of medicine, but there is no similar document that outlines the scope as
well as the boundaries of the practice of public health. Furthermore, there is no national institution a
society or an association that houses all public health professionals under one room. We do not have
the likes of the American Public Health Association or UKs Royal Society for Public Health. Well, let us
not look too far for models in ASEAN, there is the Indonesian Public Health Association and the
National Health Association of Thailand. All of them are members of the World Federation of Public
Health Associations (WFPHA). How about the Philippine Public Health Association? It is an association of
all health workers in the publicly-funded, government-administered healthcare delivery system, not a
society of professionals practicing public health. As a result, we do not have a national journal of public
health, or an annual public health conference, and we are not represented in WFPHA. I believe that
these recommendations can be undertaken through UP-CPHs convening power, being the alma mater
of the majority of public health practitioners in the Philippines.
Finally, in order for real public health goals to be fully attained in this country, the faculty and students
of the College must become more active in public health advocacy, ensuring that the products of
education and research are used to advance public health and social justice. In this manner, UP-CPH
will be able to create general awareness of public health issues and eventually influence policy reforms
and structural changes. UP-CPH must be diligent in releasing statements, calling for press conferences,
and articulating publicly stands on crucial public health issues such as climate change, human rights, and
health inequality. Public health should not fear politics, because undeniably, health is political.

All Under Public Health

In sum, I strongly believe that the challenges of public health in our country can be solved with a
renewed commitment to public health. At the very least, public health not medicine, nursing and
other health professions must be leading the way to health for all. Ultimately, the other health
professions must remain part of the public health agenda. In theory, public health encompasses the
promotive, preventive, curative and rehabilitative, and so we can say that medicine, nursing, and the
allied health professions are all part of the field of public health. Once this new public health paradigm is
cultivated in all health professions and in all health institutions in the country, then we will be one step
closer towards making our dream of health for all a reality.
A health advocate and environmentalist, Ramon Lorenzo Luis R. Guinto is a 6th year medical student at
the University of the Philippines-Philippine General Hospital. A dear friend of the UP-CPH as he worked
closely with faculty and students when he was Chairperson of the University Student Council in 20092010, Renzo hopes to take advanced studies in public health after medical school.