First, I wish to thank the DOST-PCHRD and Angeles University Foundation for presenting me with the initial opportunities to return to the Philippines as a Balik Scientist and to contribute to numerous teaching, research, and service activities across the country. Even after 25 years of being away in the United States, returning home to the Philippines felt as though it has been only 25 days—which was quite bittersweet:

  • Sweet because everything that I love about the people and the culture has not changed.
  • Bitter, because the conditions of life also appear to have not changed or improved enough over the last quarter century. From my perspective, life in the Philippines—especially in Metro Manila where I grew up—seems to have become even more challenging than before. Despite this, I am very happy to now return regularly as a public health scientist and public servant, and help in every way I can to improve the quality of lives of the Filipino people.
 
PAST: Background and Journey

I was born in Malolos, Bulacan, and raised in Valenzuela, Metro Manila. Attended Our Lady of Lourdes Elementary (until grade 4) and Santa Cecilia Elementary (grade 5) before my family moved to Los Angeles, California in 1993 when I was only 11 years old.
Fast forward to 2017—after 25 years in the US, three university degrees, and six years as a public health professor at Hawaii Pacific University (HPU)—the stars unexpectedly lined up to allow me to begin my long overdue journey back home to the Philippines, personally and professionally. To quickly frame my academic background:

  • Bachelor of Science in Kinesiology (specialized in Exercise Science)
  • Master of Arts in Health Education (specialized in Nutrition & Built Environment)
  • PhD in Health Behavior & Health Education (specialized in Mental Health, Stress, Coping, & Resilience)
Since leaving the motherland in 1993, I have always sensed a huge heartstring still attached that always reminded me of home. I remember having a fun and wonderful childhood, but I also remember the many health problems that I faced as a child in Manila including having asthma, intestinal worms, measles, mumps, falling into a sewage canal, frequent fevers, a week of waist-down paralysis (looking back, I am guessing it was polio), experiencing several near-death accidents, the ubiquitous poverty, the absence of clean tap water, the open meat markets without proper sanitation/refrigeration, the lack of healthcare access, and even almost getting kidnapped off of the street in front of my home.

Throughout my studies and work in the US, I often reminisced about my childhood experiences, my friends and families, and wanting to return to help improve public health in the Philippines. I constantly dream of a Philippines where children do not have to experience the said adversities. Looking back now, I am reminded of the decision I made to study public health in college, and it was because I wanted to end the cycle of deaths in my family that were due to heart disease, cancer, and drug abuse, among others. That is not how I want to die. I wish to die happily from natural old age and peacefully in my sleep. That is how I want everyone to die.

Guest lectures at Angeles University Foundation, De La Salle University, Holy Angel University, University of the Assumption, University of San Agustin, and University of the Philippines Manila.


In 2017, when I first began returning to the Philippines, my only mission was to establish relationships with as many Philippine universities as I could find that offered public health programs. At my university (HPU), there are many Filipino-American students, but most have never been to the Philippines, they have lost any sense of their Filipino roots, and some even reject their Filipino identity. HPU has over 200 international programs around the world but zero in the Philippines, so I have made it a personal mission to change that and create study abroad programs for students and faculty between HPU and Philippine institutions. This endeavor brought me to Angeles University Foundation, Ateneo de Manila University, De La Salle University-Manila, Holy Angel University, Saint Louis University, Silliman University, University of San Agustin, University of the Assumption, University of the East, and University of the Philippines (Manila and Diliman).   

During one of my mental health lectures at Angeles University Foundation was when the Balik Scientist Program was first mentioned by Dr. Rey Bundalian (VP of Research & Development). He then introduced me to Dr. Olga Tulabut (Assistant VP of Academic Affairs) who kindly invited me to join their team as a co-researcher with support from the Balik Scientist Program of the DOST-PCHRD.  


PRESENT: Mental Health Research

The research project led by Dr. Tulabut—titled “Mental Health Across Ages: Identifying Issues & Trends in Pampanga” and funded by the Philippine CHED DARE TO Research Grant—aims to collect baseline data and to study the mental health of the residents of Pampanga across all age groups. The interdisciplinary members of the research team include faculty and staff from Angeles University Foundation, Hawaii Pacific University, and University of the Assumption with expertise from the fields of psychology, psychiatry, guidance and counseling, nursing, medicine, education, information technology, and public health. Findings will be used to inform and guide the development of health policies and programs in government agencies, private institutions, and community centers, specifically to promote the mental health of the general public and to respond to the calls of the nation’s new Mental Health Law. 



My schedule of activities and deliverables as a Balik Scientist, hosted by Angeles University Foundation

The data collection phase of this multi-year project concluded in November 2019. The results revealed interesting mixed findings that confirmed and challenged the research team’s expectations. To summarize:

  • Among youth (Grades 1-5), about half or more of the study sample exhibited anxiety problems related to elevated panic symptoms (46%) and obsessive-compulsive symptoms (60%); in terms of depression, about 24% reported elevated to very elevated levels of functional problems.
  • Among adolescents (Grades 7-12), 40% reported moderate to severe generalized anxiety, 36% moderate to severe social anxiety, 31% provisional post-traumatic stress disorder (PTSD), 49% moderate to severe levels of depression, 54% have intentionally harmed themselves, and 17% have intentionally harmed themselves at least 5 times.
  • Among adults (20 years or older), 6% reported moderate to severe generalized anxiety, 2% moderate to severe social anxiety, 6% reported provisional PTSD, 7% moderate to severe depression, and less than 1% inflicted self-harm.
Remember, these results are from data gathered before COVID-19 interfered with our lives, and so we expect that the public’s mental health status may even be worse now. This snapshot of mental health from the general population of Pampanga sheds light on priority areas, how to intervene to promote health and prevent illness, and where these interventions could take place (e.g., schools, workplaces, communities, healthcare centers). 


FUTURE: Lessons Learned So Far and Our Next Steps

Data from this research is only a scratch on the surface of the tip of the enormous mental health iceberg. This groundbreaking effort—led by Angeles University Foundation and University of the Assumption—is among the first of many more to come. There is still so much that we do not yet understand. However, thanks to the recent Mental Health Law and to the DOST-PCHRD for prioritizing mental health in the national research agenda, the Philippines is finally recognizing and responding to the mental health needs of the Filipino people—particularly, to support important research that will help inform the development of effective and evidence-based programs and services that will meet the unique needs of the diverse communities throughout our country. 

It has been exciting to see the present works of other local institutions and researchers who are also studying the mental health of Filipinos and contributing to our knowledge base, especially now during these unprecedented times that have incredibly disrupted everything about our lives, our happiness, and our health. I look forward to working together with others and collectively build momentum in this movement.

Some next steps on my part as a continuing Balik Scientist are upcoming research projects with scholars and practitioners from Angeles University Foundation, University of San Agustin, the National Center for Mental Health, as well as several public and private healthcare centers. The purpose of these studies will be to assess the mental health of hospital workers and social workers during the COVID-19 crisis, and to develop innovative screening instruments, interventions, and programs (e.g., translation and cultural adaptation of psychometric tools, and invention of mobile apps for screening and telehealth services). I am also assisting some universities with the development of fully-online graduate programs—Master of Public Health (MPH) and Doctor of Public Health (DrPH)—to train the next generations of public health and mental health professionals.

To conclude for now, may this article serve as a call to scientists, practitioners, and students from various disciplines to pursue and contribute to research in mental health. This is also a call to our communities and organizations to seek, demand, and participate in these research efforts. Lastly, may this call serve as a reminder for all of us to collaborate, so that we could work together to fully map out and see what mental health looks like from the northernmost tip of Luzon to the southernmost tip of Mindanao. Before we can help ourselves and improve our own health as a nation and as a people, it is imperative that we have to first understand ourselves—using research data to see where we are now in terms of our well-being, where we should be in the future, and how we will collectively, effectively, and efficiently get there.


Research team members from Angeles University Foundation and University of the Assumption (Pampanga)


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As part of the PCHRD's mental health communication campaign, we have partnered with Balik Scientist Dr. Christian Gloria to release communication materials about mental health research.  The first was an introductory article written about mental health in the Philippines. This article is authored by Dr. Gloria himself to narrate his experiences as a mental health researcher and Balik Scientist in the Philippines.

The Balik Scientist Program
The Balik Scientist Program (BSP) is the brain gain initiative of the government which aims to tap into the ingenuity and expertise of Filipinos abroad to strengthen the S&T capabilities of local researchers in the academe, public and private sectors, and industry. The program was initiated to reverse the effects of brain drain, to provide researchers and scientists whose expertise are not available locally, and to accelerate the flow of new strategic technologies that are vital to national development.

  • The COVID-19 pandemic gives a new meaning to resilience thinking, with countries all over the world scrambling to find the best balance between eliminating the virus and minimizing social and economic damage.
  • Dr. Ronald Law, Chief of the Preparedness Division of the Department of Health-Health Emergency Management Bureau, shares his insights on the role of science and research to combat COVID-19 and the knowledge gaps that need to be addressed to implement timely public health interventions to control transmission and prevent resurgence of cases.
  •  This post is a commentary contribution and does not necessarily reflect the views of the Department of Science and Technology-Philippine Council for Health Research and Development (DOST-PCHRD).

 

If our well-being or survival in this pandemic were to depend on how much or little we know about the science of COVID-19, then we need to sound the alarm now for rapid, quality and equitable research on COVID-19. 

While we’re lost in the business (and busyness) of response, it is imperative for us to find our way to addressing knowledge gaps that when answered can shine a good light on what directions we need to take and how to go about the journey. We can’t forever grope in the dark--it’s a sure recipe for a disaster within a disaster. Science and resilience thinking should be that light with research paving the way.

Aside from political will, public health expertise, government resources, social capital and other “effective” interventions in the pandemic playbook being written across the globe, the role of research should be front and center especially now more than ever.

Almost 8 months from waking into this surreal if not harrowing world that is filled with uncertainties, the only thing certain about COVID-19 is that it is too complex that we have more questions than answers that science can find.

While all of humanity’s labors and hopes are pinned on the medical aspect of research—the discovery of a vaccine or a group of drugs to protect against the virus or quell the negative health effects of the disease, several public health aspects that pertain to transmission, prevention, control and risk management remain to be poorly elucidated.

Let us count the ways and measure how wide the knowledge gaps are.

There is evidence that COVID-19 is a zoonotic disease--can be passed from animals to humans but up to now, the animal reservoir or habitat where the virus thrives and other animal hosts in the chain of infection are not yet well-defined. Bats, rodents, cats, dogs, the list goes on.

It is established that the elderly population (above 60 years old) and those with underlying medical conditions are the high risk groups for infection.  However, the specific conditions--diseases, health status, predisposing factors and indicators for severe disease are not yet as clear.  It is perplexing to note why some young people can develop severe infections even without comorbid conditions.

It is known that transmission can happen 1-3 days before the onset of symptoms but there is still no data to describe the magnitude and extent of asymptomatic and pre-symptomatic transmission let alone the infectious dose of the virus.

Globally, only 1-3% of cases is attributed to the 0 to 19-year age group. Children show lower risk of infections and when they do, the usual symptoms may not be observed. But just how susceptible and infectious they are compared to adults are still burning questions.

It is widely held that timely public health interventions are essential to control transmission and we know that countries which have employed a mix of public health and social measures have already been successful to a certain extent; but despite all the elaborate models that data scientists can churn out, what specific combination of interventions is needed to prevent resurgence of cases? What is the impact of individual and combined public health and social measures on COVID-19 and non-COVID-19 issues alike?  These are not yet found in the vast literature.

We’ve seen that transmission is common in closed settings (hospitals, prisons, public transport) and super-spreading events are responsible for the exponential rise of cases. But key questions are: What are the characteristics of these settings? What are the main transmission routes? What are risk factors of people in these settings?

In terms of infection prevention and control, we know that droplet spread is the main route of transmission and that masks of different kinds afford some protection from the virus. Recently, evidence on airborne transmission is already coming to fore. But up to now, effectiveness, adverse events, and sustainability of use of masks, respirators and face shields still have to be investigated.  Likewise, in environmental health, we are still grappling with the ideas of spread of the virus in water and fecal matter, role of fomites (inanimate objects like doorknobs, mobile phones, elevator button) in spreading the disease and effective technologies for decontamination.

Lastly, we know that the pandemic disproportionately affects the population. When it comes to strengthening response and addressing social justice, these questions linger: How uneven are the impacts to different social groups in specific settings and contexts? What is the importance of adaptation and the role of communities in response and mitigation? We still need to crunch some data to back up these relevant arguments so governments are properly guided on prioritization of target groups, resource allocation and resilience planning in the new normal.

While (im)patiently waiting for the outcomes of massive global trials for vaccines and treatment, these public health research questions that span epidemiology, health policy, environmental health and social sciences are more than enough to preoccupy the best minds of our scientific and medical communities the world over and in the Philippines.

More than enumerating these as part of a robust research agenda, the Philippine research community should commit to implement relevant research that will support our collective pandemic response. This is the most “science-based” strategy as we can ever get. Also, the government is called to the challenge of mustering its energy and marshalling its resources to convene experts from different fields, disciplines and institutions, to build on their rich trove of expertise, resources and networks, to work on this ambitious but future-defining agenda.

Lastly, we need to adopt a research mindset that frames the success stories of other countries from a global perspective and perceives our own good practices on the ground as practical evidence that can make a big difference in our response. We can learn or unlearn a thing or two on this. And no one can argue with us on that.

 

Aside from his position in the DOH, the author is a professor of public health at the University of the Philippines-College of Public Health, UERM Memorial Medical Center Graduate School, Ateneo School of Medicine and Public Health and the University of Washington in the U.S.

He is a recent US-ASEAN Fulbright scholar focused on health security, emergencies and disasters. He is also part of the technical working group working on the health resilience thread of the National Unified Health Research Agenda (NUHRA) and a member of the DOST-PCHRD Disaster Risk Reduction - Climate Change Adaptation (DRR-CCA) Program Technical Advisory Group.

The 2020 World Congress of Bioethics confers the Medard Hilhorst for Oceania region  prize to the poster, “When Reviewers are Reviewed: obstacles and ethical dilemmas when ethics reviewers themselves are the subjects of study,” based on  a study funded by the Department of Science and Technology - Philippine Council for Health Research and Development (DOST-PCHRD).

From the project “Gender Competence in Ethics Review in the Philippines” led by Professor Fatima Alvarez Castillo, current president of the Social Inquiry and Building Capacities in Research, Inc. (SIBCRI), the winning poster highlights ethical dilemmas encountered in the aforementioned study. The poster was authored by Daphne Joyce Maza and Joel Estacio who were assistant investigators of the project.

In the study, gender competence is defined as the “knowledge and ability to recognize risks, harm, vulnerabilities, discrimination, and other forms of unfairness for research participants that ensue from gender.” To examine gender competence in Philippine ethics review, the researchers interviewed ethics reviewers and gender experts.

We realize that gender issues are often unrecognized or unseen even among those who are highly educated,” Prof. Castillo said about the team’s motivation in pursuing the project. This was affirmed by the results of the study which found that there is a need for considerable improvements in gender competence among  ethics reviewers. Aside from misconceptions about gender, there were gaps in addressing gender issues in ethics review.

One recommendation of the research team is for the Philippine Health Research Ethics Board (PHREB) to create policies that could strengthen the gender competence of research ethics committees. The PHREB may identify gender competence as a mainstream competence among RECs, incorporating it in the accreditation processes of RECS as well as in capacity building activities and programs.

As the national coordinating agency for health research efforts in the country, we recognize ethics review as an equally important part of the research process,” said DOST-PCHRD Executive Director Jaime Montoya. “We must ensure that our health research community gears towards the advancement of healthcare without compromising the rights and welfare of research participants regardless of gender,” added Dr. Montoya.

From the team’s experience in joining the 2020 World Congress of Bioethics, Prof. Castillo encourages the country’s bioethics community to take an active role in fostering a robust ethical research culture in the country by continuing to study and address existing issues in ethics review. Having faced challenges as well in conducting their study, Prof. Castillo advises researchers to persevere and collaborate with their respective ethics committees to overcome obstacles.

The submission “Gender Competence in Ethics Review in the Philippines” was also shortlisted for the Mark Ehrenreich Prize in Healthcare Ethics for the Oceania region, a paper presentation category in the 2020 World Congress of Bioethics. The co-investigators of the study are Nimfa Bracamonte, Ernesto Gregorio Jr and Erlinda Palaganas.

 

In an effort to strengthen individual, institutional, and sectoral research capacity in the Philippines, the Department of Science and Technology – Philippine Council for Health Research and Development (DOST-PCHRD) partners with various host institutions, offering opportunities to researchers to benefit from and contribute to the development of new knowledge and drive innovation in the field of health research.

One of the long-standing partnerships formed by the Council is with the Department of Health - Health Policy Development and Planning Bureau (DOH-HPDPB) for the implementation of the DOH - Health Policy and Systems Research (DOH HPSR) Fellowship Program under the DOH - Advancing Health through Evidence-Assisted Decisions (DOH-AHEAD) strategy.

The two-year program aims to establish a cadre of young professionals with the appropriate knowledge, skills and attitude to appraise and conduct high quality health policy and systems research. DOST-PCHRD facilitates the applicant screening process, disbursement of financial incentives, and monitoring of the fellows’ development and progress all throughout the program.

Last June 29, a virtual research defense was conducted for the 2018-2020 DOH HPSR fellows and interns as one of their final requirements for the conferment of the program’s certificate of completion. Two study groups presented their completed research proposals to panelists from the DOH and external experts.

The first study group presented the current situation of public health financing schemes in terms of equitable access for family planning services. The second study group presented the assessment of the Philippine National AIDS Council’s implementation of multisectoral approach on HIV/AIDS response in the country to gain understanding of the elements that make multisectoral approach function effectively to achieve health sector goals.

Since 2012, the HPSR Fellowship Program was able to capacitate more than 200 young and emerging health research fellows whose research outputs have already been used in improving health programs and services for the Filipino people. Some of these outputs include research on “Rapid HIV Diagnostic Algorithm (rHIVda) for the Philippines,” “GeneXpert (Xpert MTB/Rif) in Multi-Drug Resistant Tuberculosis,” and “ECMO for Pulmonary Hemorrhage Secondary to Leptospirosis.”

 

As the Philippines enters the peak typhoon season, small islands like Marinduque are placed at a higher risk to extreme weather events a looming plight that coincides with the still existing COVID-19 pandemic.

When there is an impending weather event, it is vital to assess its health risks to vulnerable communities. This will enable locals and officials to act and prepare with sufficient time to avoid threats to health, harm, and casualties. Coupled with early warning systems, populations at greater risk will be equipped with proper tools to get useful information for better disaster preparedness and response.

This is the impetus for Dr. Delia Senoro’s team at Mapua University in devising the eSalba mobile and web-based application that empowers both households and local government units (LGUs) to strengthen the health resiliency of small communities by enabling locals to report an incident to authorities, thereby allowing quicker and more coordinated disaster response of LGUs as it provides locations of reporters, responders, evacuation and health centers in the community.

          

As an assistive, modernized, and enhanced early warning and communication tool, one unique feature of eSalba is that it generates data for health vulnerability map of communities, allowing locals, decision-makers, and responders to view populations that are most vulnerable to health-related outcomes brought by disasters and other socioeconomic factors. 

With the capability to warn about possible health disease outbreaks in a specific area, the app will strengthen preparedness and management of LGUs to both impending disasters and health-related problems as it provides useful information needed for short-term response and long-term policymaking, development, and improvement.

Planned to benefit the LGUs, particularly barangay and municipal health workers, Disaster Risk Reduction and Management Offices (DRRMOs) at the municipal and provincial level, the eSalba is expected to reach the communities in Marinduque before September 2020. 

This initiative is a component of the program commonly referred to as D-HIVE (Development of Health Index: Vulnerability to Extreme Environmental Events) for Marinduque Island, funded under the Disaster Risk Reduction and Climate Change Adaptation (DRR-CCA) research program of the Department of Science and Technology-Philippine Council for Health Research and Development (DOST-PCHRD).

The app has undergone its first test run last June 29, 2020 which was participated in by 42 Marinduque locals composed of barangay officials, local health workers, SK Chairperson, MDRRMO staff, and D-HIVE Team.