Relative Joy

The relationship between the physician and the pharmaceutical industry is once again put in the spotlight due to an alleged “pyramid scheme” from doctors who engage in getting credits in exchange for prescriptions AND enticing colleagues to prescribe the products of the pharmaceutical company in order to earn additional credits and benefits.

The Philippine Food and Drug Authority issued FDA circular 2013-0124 on September 5, 2013 which adopts The Mexico City Principles (https://www.fda.gov.ph/wp-content/uploads/2021/08/The-Mexico-City-Principles.pdf) for Voluntary Codes of Business Ethics in the Biopharmaceutical Sector.

The MCP was adopted in 2011 during the US APEC host year and was recognized by APEC leaders and ministers.

Six principles form the pillars of the MCP:

1. Healthcare and patient focus means everything we do is intended to benefit patients.

2. Integrity means dealing ethically, honestly and respectfully in everything we do.

3. Independence means to respect the autonomous decision-making of all parties, free from improper influence.

4. Legitimate intent means that everything we do is for the right reasons, is lawful, and aligns with the spirit and values of these principles.

5. Transparency means a general willingness to be open about our actions while respecting the legitimate commercial sensitivities and intellectual property rights.

6. Accountability means a willingness to be responsible for our actions and interactions.

During my term as director for the CDRR at the FDA, we constantly monitored and reminded the industry to manage their entanglements with physicians. While it is not wrong to promote any biopharmaceutical product, promotions should be within the scientific merits of the product, sans pomp and enticement.

Some physicians may not be able to discern entanglements with the industry as some believe that “gifts” are entitlements to them. There is no such thing as a free lunch.

The greater the value the gift, the greater the responsibility. Gifts do not need to be ostentatious to be a bribe. A bribe is a bribe, regardless of value. It is the intent that is crucial.

A lawyer commented that this practice is not illegal, but it is unethical.

Undue influence is legally defined as “influence by which a person is induced to act otherwise than by their own free will or without adequate attention to the consequences”. Undue influence clouds clinical judgement in the healthcare system.

The practice of medicine is not a business. Our relationship with patients rely on trust, compassion and respect. There should be no lines that blur the relationship between doctors and patients at all touch points.

And the guiding principles of ethics – TO FIRST DO NO HARM – is the overarching dictum that should be followed.

In January of 2019, my mom who was then 82 was diagnosed with colon cancer (Stage IIIA).

She underwent surgery on February of the same year, but refused to undergo chemotherapy. She said that she was old already and did not want to have to struggle with ‘quality of life’ issues. We actually had bookings for our trip to Tokyo in March of the same year. A month after her surgery, she struggled to make it with us to the trip.

It’s been five years (and more) since her surgery, and it’s been a roller coaster ride of having to deal with health issues. With the love and care of her family – my niece, nephew, sister and my partner – we were able to manage through several speed bumps on health.

I’ve always believed in the power of prayers. Sometimes, when we ask for those small miracles, someone up there listens to us. As a man of science, I believe that we are only instruments of God.

On a balmy Maundy Thursday in Tokyo, my mom wanted to visit a church. Unfortunately, we could not use the PWD lift because there was no one around but the Tsukiji Catholic Church (https://tsukijicatholic.org) was open. We spent 30 minutes there in meditation, thanking God for the extended journey in her life.

Unlike our trip last year where we stayed in the hustle and bustle of Ginza, this time around was a more reflective one. (Did I not blog about how reflections killed my Apple Watch?)

We spent more time bonding and enjoying each other’s company. At my age, I began contemplating more on what my mom’s journey was and how my journey of accepting struggles and resilience brought me to where I am today. No complaints. No regrets. Just pure acceptance.

Because love, is what pulled us through those difficult times.

Love, was the miracle.

The first Apple Watch Series 1 came out in 2016, I was one of those who flew to Tokyo to grab one.

There was that fascination over, yes, owning a watch that synced with your phone, apps and all!

Over the years, the Apple Watch evolved as technology advanced as quickly as the iPhone.

As quickly as the phones changed, so did the watches. And the other digital devices.

A few years after the launch of the Apples Watch, many other brands came out with their own versions of the “smart watch”. And smart phones.

I have nothing against technology. In reality, I am one of those who embraced the craze.

On our recent trip to Tokyo, one realization struck me when my Apple Watch died on me. Yes. It literally lost power several times. And I knew this 5 year old watch (yes it was a series 4), was ready to retire.

And while I was looking at my “dead” watch at Shinjuku, the realities that struck me were:

1. The watches had no resale value. These smart watches had a life span. They don’t last like the phones and no matter how expensive

It’s been awhile since I posted a blog.

I know that many followed this blog for the COVID-19 updates during the difficult times of the pandemic. As we saw better outcomes with vaccination and treatment, you will agree with me that it is time to move on, albeit still cautious of how SARS-CoV-2 can possibly evolve in the future.

With that said, I chose the Greek word Ataraxia as the title for this blog.

It means, “a serene state of calmness, freedom from worry.”

The past three years have truly been difficult. Not only in terms of healthcare and economy, but the overall anxiety driven by the pandemic.

There are many who still live in perpetual fear of catching COVID-19 and still many who are confused with the isolation and quarantine rules when one tests positive for the virus.

Without a doubt, majority of the infections we are seeing now are mild.

I tested positive for COVID on May 1, 2023.

Because it was a holiday, I had a 3 km run in the morning of this very warm day. After a good shower, I asked my family to have lunch in the mall. We always pick sitting outside (where there is good ventilation) in spite of the heat. After lunch, we went around the mall (with masks on). I told my mom that I felt a bit exhausted (and attributed it most likely to both the heat and the run). We went home early and I took a nap and woke up feeling better.

But better wasn’t good for me. That’s because this was unusual. I do some runs but don’t feel winded down. And because there were so many sick kids in the clinic lately, I decided to swab myself. And I was positive.

I didn’t have any other symptoms. No fever, cough, cold or loss of taste and smell or pain. Nothing at all. But I isolated for 5 days and continued to wear a mask up to day 10. I was already negative on the 7th day (with day 0 being the first day I tested positive) and a repeat test on the 9th day continued to be negative. I short, I was fattening myself for a week and binging on Netflix and Disney Plus and working online.

It dawned on me – how many people had symptoms similar to mine and did not bother to test? As I’ve always told my patients, you don’t need to have fever to be positive for COVID-19.

None of my family who were exposed to me had COVID. Maybe because they all had COVID infection already 6 months ago and I was the only one left in the household that has not had natural COVID infection. Could it also be due to the fact that I received my bivalent in the US in October 2022 that I was ‘protected’ for a couple of months? But the circulating strains currently are not covered anymore by the bivalent vaccines that are being provided.

That week of catching COVID gave me time to mull and think about life after COVID infection. This will most likely be a viral infection we all will catch (just like influenza) and there will be a variety of circulating strains from a dominant variant and sub variants. Those that have had the natural infection will have more robust protection and those that have had vaccination will be protected against more severe clinical illness.

Catching COVID taught me a valuable lesson in medicine post-COVID.

Ataraxia should be how we look at the current COVID situation.

Work. Eat. Drink. Travel. Relax. Have fun. Repeat…

Life, after all, should be celebrated.

Nobody saw it coming.

Not even the experts at disaster preparedness. It took the World Health Organization to even decide calling the SARS-CoV-2 outbreak in China, a pandemic.

Like a thief in the night, COVID-19 stealthily took over our lives and changed the way we lived in the last three years. Even as the WHO declared that COVID-19 is not a public health emergency any longer, those three years were undoubtedly painful ones.

People needed to change behavior. With high mortality at the beginning of the pandemic in the 21st century, science needed to step up quickly in order to find treatment and vaccines against the virus.

Unfortunately, as science raced to address the gaps of healthcare, the virus mutated to more evasive variants and sub variants. They too, needed to survive.

The casualty of the COVID-19 pandemic was not only health-related. Deaths, post-COVID sequelae, and other unaddressed health issues which were not attended to during the pandemic because of fear of going to hospitals and contracting the virus was something we needed to address. Immunization against common preventable diseases were placed on hold. Necessary work-ups for other ailments were on pause mode, worsening the saddled healthcare systems globally.

But health wasn’t the only major casualty of the pandemic.

The economy of various countries, particularly those that remained in lockdown for the longest period of time suffered the most. People lost their jobs because businesses had to close. Those that survived would need time to recover the 2019 numbers. And it’s not going to happen overnight. It will take more resources and deeper pockets to continue operating the same way we did 4 years ago.

There are lessons learned from this pandemic.

Lockdowns don’t work, particularly for poor countries like the Philippines, where majority of its people live below the poverty line. The fear of contracting the virus and getting sick was coupled with some very poor decision making from the previous administration. A bitter pill of truth that is difficult to swallow.

Disaster preparedness will require a political will. This will not be the last pandemic to strike us. If there are those in government who will misuse and abuse the coffers of the health department, we will end up waiting like beggars for dole-outs from donor countries for vaccines and medicines. By then, it would be too late.

If you look at the situation we are in today, we are still at the sad place in health.

We have little regard for the healthcare sector, and its healthcare workers. There is no budget for vaccines for its people and we remain mendicants in many aspects of health.

Quo vadis Pilipinas?

This isn’t a paid review.

A lot of people wonder how we were even able to get a room here. It’s not like a swanky hotel. It’s actually four stars. This reservation was made 6 months ahead of our planned trip. Hoping that nothing would come in the way, I went ahead and booked the three rooms for a party of six adults.

Located right smack in the Ginza district, this hotel has the minimalist and environmental-friendly feel. The location is the crown jewel stand out for this hotel. Right in the heart of the Ginza district, where the posh high-end shops are never ending, the hotel is just a few steps away from Mitsuhikoya and Matsukaya Ginza, as well as the branded names of Fendi, LV, Gucci, Prada, Hermés, Bottega Venetta, Valentino, et al, or the likes of Apple and Samsung flagship shops, Ginza is home to several Michelin starred restaurants and the more upscale Tokyo Peninsula.

So why pick the Muji Hotel at Ginza? But this hotel is not without hiccups! Aside from the aforementioned location, the flagship Muji shop is located on the first five floors and a Muji Diner at the basement of this building. The hotel, with 79 rooms, is located on the 6th to 10th floor. The stores and diner close at 9pm daily. That means the access to the hotel from the main shop closes as well. You will need to use the hotel entrance at the back of the store to gain access to your rooms after 9pm.

The reception is located on the 6th floor. There is no luggage service, so don’t expect a baggage boy come rushing to the doorstep to meet you. There is also hardly anyone at the front desk after 11pm. When we arrived close to 11pm last Sunday, I called the hotel and was asking where the entrance was, we couldn’t understand each other. While the staff may speak English, it’s quite basic and things get lost easily in translation. This is, after all, not the Four Seasons at Maranouchi (a favorite of mine).

The rooms are decent. Most of them follow a type C design. In reality, when Muji had bought this building, it was originally designed to be an office and not a hotel. Which accounts for the way the interiors of the hotel have been retrofitted to an appealing but not functional look.

There are standard amenities which you can take home with you. It’s a mini version of what you can find at the Muji store.

As modern as it gets, there isn’t a switch in the room (except the bathroom). All appliances, lights, curtains, alarm, cleaning services and phone calls are made through a smart pad. That includes the level of lighting and whatever you’d want to operate in your room without having to stand up. Just bring the tablet with you to control all settings.

Breakfast does not stuff your face in a buffet. Although still a buffet, it’s a rather simple spread of traditional Japanese dishes. Breakfast is at the WA Restaurant to the left of the front desk. To the right of the front desk is The Atelier – Muji’s library – where there are tons of reading material and coffee, tea and some baked goods. The bakery is located in the first floor, while the diner is at the basement. The bakery and diner are open after 11am. Food choices are standard and limited.

Your stay at the Muji Hotel won’t be complete if you don’t visit their whole 5 floors of shop – from fashion to household needs and appliances to school and office supplies and to their famous diffusers and scents.

Here’s the photo gallery of the five floors of the Muji store below the hotel.

The Muji Hotel at Ginza has its plus and minuses. With Uniqlo and GU just at its side and the posh shops a few steps away, it is, hands down, the best location in Ginza.

But if you’re looking for a hotel with less hits and misses, Muji Hotel at Ginza is over rated as an eco friendly hotel doesn’t really work well for the elderly and persons with disability. If you fall into the latter category, this should not be a choice for you.

It’s also stressful that they require all guests to check out promptly at 11am. And they need all the card keys when you check out (so that means that there’s no taking home those card keys as a souvenir). But there is always a place to put your bags in the lobby and you can always have lunch at WA if you’re waiting for a late afternoon flight.

You can reserve a room online at this link: https://hotel.muji.com/ginza/en/

Japan culture and Japan itself is my go to place when it comes to Asian countries. A country deep in history, it also enjoys the climate one would truly appreciate when it comes to experiencing the four seasons of the year. Japanese people are respectful and their traditions remain deep in honor and accountability in spite of the rapid changing technology and generation gaps in this ultra-fast paced century.

The lockdown years were frustrating for those who enjoy traveling. And traveling is what my mom even at the age of 85 and wheelchair bound, enjoys. In spite of the physical and emotional challenges in life, traveling and relaxation makes her difficult life easier to get by.

The post-lockdown travel is a challenge – not only to those who are able-bodied but more so, to the physically handicapped.

Current travel requirements to Japan include full vaccination and ONE booster. Nope, Sputnik vaccines do not count. And if you only have a full vaccination or your full vaccination was a Sputnik vaccine and you had ONE booster of any other COVID vaccine brand, that didn’t count either. What to do? Get an RT-PCR, 72 hours before your flight. Validity for that PCR test is 72 hours prior to your designated flight.

You will need to fill up your travel details on this website https://www.vjw.digital.go.jp/main/#/vjwplo001 and upload the quarantine requirements (vaccine certificates), obtain an immigration QR code, and obtain a customs QR code as well.

When your digital requirements are fulfilled, you should be able to get all these within less than 12 hours. The immigration and customs QR code are almost immediate. Don’t forget to take a photo shot of your QR codes and save to your photo gallery, just in case you don’t get a wifi signal or you’re too stingy to go for data roaming on your mobile phone.

The long Holy Week and holidays contributed to the exodus of Filipinos from the city. The airport was crowded and the immigration line was bad. Everyone wanted to be part of the “priority” (senior citizens and PWD lane) with the kids, teenagers and everyone else in their traveling party in tow. Discipline isn’t really part of the DNA of the Filipino.

Even boarding was mayhem in Manila. When the ground crew began to announce that boarding for children would commence – the rush to the gate was like all hell had broken loose. It’s like – didn’t you get a seat assignment?

The four and a half hour travel to Japan on ANA was smooth. Food was served promptly. But the choices on the Manila to Haneda leg wasn’t really great. You’d think that paying for business class you get you more than just slippers and a heavy blanket – but more decent choices as well. The over-all cabin crew service, however, was superb and made up for what was basically lacking in the business class food service.

Did I mention the cabin crew? Yes I did and this cabin crew really did a great job in attending to my mom, in spite of the 3/4 full business class flight. And here’s the icing on the cake…

Upon arrival in Haneda, we would need to use a bus gate. That would mean stairs! Fifteen minutes before the arrival into Haneda, the chief purser had informed me of this. We were instructed that when we arrive and all the passengers have deplaned, there would be a special arrangement for my mom who would be hauled by traction down through the door on the right side of the plane where the special bus would connect us to a vehicle that would attach to the “cargo” and take us straight into the gate near the immigration area.

I was literally blown away with the service of ANA and the crew at the Haneda International Airport. Two staff were with us from the time she was shuffled from the plane into her own wheelchair, to the queue at immigration (in the priority lane), until we got our baggages, till we met our chauffeur at the arrival area.

Great job ANA and domo-arigato (どうもありがとう) to team ANA!

[On a side note, the average duration from arrival to exit took the other members of our party 2 hours to queue in Haneda. So many tourists arriving that same evening! In spite of the fact that we waited till the whole plane was emptied of passengers before we could deplane, and took our ‘private’ transfers from the bus gate to immigration, we were finished within an hour after our arrival into Haneda. The Japanese immigration was not spared from the stampede of tourist arrivals. All those who had kids in tow (even if they were not with children less than 2 years old or who did not require strollers or assistance) were on the same ‘priority’ lane as the elderly and disabled. The woman triaging the passengers was completely overwhelmed at the multitude of arrivals that compounded with the language barrier, there was nothing much she could do.]

To date, I have had close to 3.6M views and over 1800 quotes and close to 500 likes for a post in Twitter. As the Twitter language would put it – I was ‘ratioed’ (not grammatically correct but as those that coined this would say – who cares!). It means that there were more dislikes (and reactions) than likes from various sectors.

We all know that Twitter has very limited character typing and you really cannot keep making a whole trail of events, but let’s capture that now in the proper context. [Apologies if the context was not provided the way people wanted the whole story told.]

I run a company (own) that is hiring additional personnel. We are a healthcare industry. There were several applicants. We interviewed them all. Decided on one qualified applicant. Invited the applicant over for the the job offer. Discussed with the applicant that we offer a month of sick leave, vacation leaves, all convertible to cash and cumulative (which means if it is not used this year can be used in subsequent years for tenure incentive). There’s also a 14th month pay and profit sharing bonus. The pay was above average standards for the industry [which means that we’d be shaving from our budget this year but well, we just needed to be fair to the employees in these trying times].

The applicant requested to ‘think about the offer’ and get back to us in 7 days because the family was traveling outside the country. Although we needed the placement ASAP, I acceded. HR informed the applicant to decide soonest so that we can fill the service gap, which is vital in the healthcare industry.

After 2 weeks, I requested HR to kindly follow-up with the applicant on the decision. The applicant said, yes, but there was an added request – to provide additional paid vacation leaves.

Of course, I was stunned because that would mean that if we gave in to one, we would need to change the whole company handbook. And that would mean also additional expenditures for the company. [Please remember that providing added leaves would mean we are understaffed and that would mean hiring more people again and the vicious cycle continues.]

And at the end of the day, we compromise patient services resulting in poor patient care.

I asked politely why the applicant needed additional PAID LEAVES. The reply was that the applicant had several circle of commitments outside of work – friends, social organizations, bonding time with colleagues for networking purposes and exploring additional opportunities outside of working for us.

While the applicant was qualified, we did not share the vision that the healthcare industry cannot have a similar work life balance relationship the way the applicant envisioned. [Note here is that we encourage people to use their leaves so that they can have a good work life balance. Unfortunately, we cannot over stretch this to more than a month.]

In fairness to the company, during the lockdowns, we drained resources in order to provide private shuttle services to and from work for the workforce. We provided added sick leaves and COVID19 leaves with pay. We sent swab kits to the families of the workforce when anyone was sick or needed to get tested. The HMO coverages to employees who got sick and needed hospitalization came in handy.

The healthcare business is different from other industries. And without having to sound offensive to the dissenting Twitters out there – is not comparable to any other work from home or hybrid playground you are currently in. Sure you can get a consultation online with a doctor who may be sipping Margarita enjoying the sunset in an idyllic resort, but that’s not the right way to assess sick patients. You will most likely miss 50% of the right diagnosis and make as much error in prescribing the right medicine with an online consultation, especially for acute illnesses. [I’m not saying a virtual consultation does not help, I’m just saying it’s not the ideal way of seeing acutely sick patients and may increase morbidity if not addressed correctly.]

The gap in the delivery of healthcare services is palpably felt not only in the Philippines, but globally as well. That’s why our healthcare workers prefer to leave for better pay and opportunities to care for foreigners rather their own people. I cannot blame them.

But we have a nation of 115M Filipinos to care for. A sizable chunk is the growing elderly population whose medical needs have incrementally increased during the pandemic. As a matter of fact, they were the most vulnerable and it was heart breaking to see friends and relatives succumb to this. Then there were those who came down with COVID-19 and post-COVID problems (long COVID). This took a toll among patients from all walks of life.

The healthcare industry was affected mentally, emotionally and economically. Healthcare workers who were my dearest friends passed away from COVID. Many of the frontline healthcare workers simply gave up from sheer exhaustion and moved to office jobs. Many older doctors just closed their clinics and went into retirement. Hospitals and clinics were understaffed. And the cycle of surges and lockdowns and deaths pushed other healthcare workers into just throwing in the towel. While we are seemingly at a better situation today than three years ago, the first three years of the pandemic upended many things.

The pandemic allowed innovation and technology to be part of the solution at the front and center of the work force. This allowed the economy to push on, albeit slowly, in the local and global front. Undoubtedly, the Philippines still had the poorest working conditions especially in the health sector. Underpaid. Overworked. The government did not care for its healthcare work force leaving them begging for the scraps that were promised and due them.

Many left the country. And that created wider gaps in healthcare. Hospitals now run at half its bed capacity because we have a shortage of work force – in all areas. Often times, a procedure would have to be moved to another day or that you’d need to wait in vain for a bed – not because we have no room at the inn. But because we have less people to care for the sick. And it’s heart breaking to see your next of kin, father, mother, brother, sister, friend or family wilt away or have to move from hospital to hospital because of the challenges the pandemic created in the healthcare system.

Today, we’re trying to rise out of the rubble of a pandemic.

This was explained to the applicant and sadly, it ended in a no deal.

The frustration here is that the applicant could have told us earlier during the negotiations what other wants, requests and other needs the applicant needed. If it was unacceptable from the get go, then we both could have walked away and not wasted each others time.

Now it’s back to square one. A whole month wasted on interviews, offers and negotiations.

In the meantime, the sick are piling up across the hall.