Friday, January 30, 2015

Remembering and forgetting: Reflections on Alzheimer's Disease

With my grandaunt Tarcila Lasco
by Gideon Lasco, MD

To grow old, many people think nowadays, is to become forgetful. We speak of "senior moments" as lapses of memory, and we are all too familiar with old people being ulyanin and having Alzheimer's disease. According to one study, almost 40 per cent of people over the age of 65 experience some form of memory loss.

Doctors make a distinction among various types of dementia, which may be confusing in real life as they often overlap. These include vascular dementia, the loss of memory and cognition that comes after a stroke. More commonly, there’s Alzheimer's Disease, a progressive degeneration of brain cells that runs its course through several years. Moreover, dementia is not to be confused with “age-associated memory impairment”, which is part of the normal aging process.

But in many cultures, to grow old is also to be full of experiences and memories. Among the Badjao, Italian anthropologist Bruno Bottignolo writes that the people have no concept of chronological age, and do not even know how old their children are. For the Badjao “what counts are the significant moments.” Similarly, when I traveled around the country to interview indigenous healers, who were mostly old men and women, some of them don’t know their real age, and would instead relate the chronology of their lives with events like World War II, the Martial Law, or which president was in office. As repositories of collective memories, old men and women were valued for their counsel and sought for their opinions.

We can still see traces of this in our own culture. The Tagalog term for old is luma, but for old persons it is matanda, a cognate of tanda, which means ‘to remember’. Indeed, we could take this to mean that our forebears marked age not by number of years, but by the number of memories.

***

I became mindful of these things when my grandaunt, Lola Tarcila, passed away at the age of 88. For more than a decade, she had suffered from Alzheimer's disease. As a medical student, and then as the only doctor in our family, I had followed the course of her illness, from the time that she began to lose track of our birthdays, to the time that she could no longer recognize herself in the mirror.

She never married throughout her life. Instead, she became a mother to everyone in our family, and supported the education of many of her nephews and nieces. And although she never wed, the sweetheart of her youth was always her refrain, even as all else has faded in her memory. “We would have been together...but I just did not want to elope with him,” she would always repeat, even to strangers, with an air of nostalgia.

The realization that something was wrong with her came to us when she began to misplace items. Keys would disappear, only to be found in the most obscure drawers. Then she began to forget birthdays and anniversaries. Soon, she lost track of the calendar, and every day she would ask whether it will be Sunday tomorrow. Slowly but steadily, her memory began to fade.

Then the day came when she could no longer recognize me, conflating me with my father, brother, or one of my uncles. But in rare moments of lucidity that gave me joy, she would tell others that one of her grandnephews would soon be a doctor. One day, we saw her talking with herself at the mirror, thinking that it was another lady in front of her. But even then, her graciousness never left, politely asking her own image whether she would like to come and have dinner with us.

Visitors came to see her - family and friends - but as the years passed, the visits became fewer and further apart, While everyone she knew kept their high regard for her, perhaps this was inevitable as she could no longer take part in conversations. It was as if the Tarcila they knew no longer existed. Looking back, I realise that the tragedy of Alzheimer’s disease is not just that you forget people, but that people forget about you.

***

On August 2013, Lola Tarcila died peacefully in her sleep, after 15 years of Alzheimer’s. I had only been 12 years old when she started losing her memory. Gone from us is is my dear grandaunt who cooked the best bulalo, prepared the best leche flan. Her industriousness and generosity have been life-changing for many of her loved ones. But, alas, the intervening years have blunted the impact of her loss. How could I forget the voice that lulled me to sleep when the world was yet bright and new? Yet, even as I race to remember those times, I knew that my efforts are bound to fail, for the details have slipped.

Could it be that Alzheimer's disease is a metaphor of the human condition? We go through life as parents and children, brothers and sisters, lovers and friends, and these bonds are initiated and perpetuated by physical connections, of joy and sorrow, of triumph and defeat, of love and hate, of constancy and change, of distance and intimacy. But even as we etch these things in our memories, and convince ourselves that there they will remain forever, they begin to fade at the moment of their inception. And when the time has come to recover them anew, we realize, sometimes in tears, sometimes with indifference, that very little has remained.

To hold on to these memories, and to never let them go: This then is humanity's only resort. It is not in the inevitability of forgetting, but in the struggle of remembering, that we are able to rise above the illness of corruptible memories that afflict all of us, some in dramatic fashion, others in far subtler ways. Just as Lola Tarcila, even in her amnesiac state, never forgot her sweetheart, though several decades have passed, so too will I try to never let go of the elders who have touched my life. To look at them as matanda: full of memories, and to fill ourselves with memories of them: this is what will allow us to cherish them in life and treasure them in death and beyond. Indeed, we should strive to carry them in our hearts until our own capacity for memory and life has gone.

When all remedies have failed, there is still remembrance.

Puerto Princesa
January 31, 2015

Wednesday, January 21, 2015

Mt. Cloud Bookshop in Baguio City: A treasure-trove of Philippine culture and scholarship

BAGUIO CITY - One of my favorite stops here in the City of Pines is the historic Casa Vallejo in Upper Session Road. Dating to 1909, a year before the establishment of Baguio City itself, it is among the oldest surviving structures in the city, surviving both World War II and the Baguio earthquake of 1990. Just as it has been at some points in its storied life, it is now a boutique hotel, and the venue of other interesting establishments. Aside from the fantastic Hill Station Restaurant, the North Haven Spa, and even a art-flim cinema, it is home to Mt. Cloud Bookshop

“We don’t just sell books, we love them!” one of the posters read. And I must add that the bookshop owners must have a special affection for books of and about Filipinos and the Philippines.

Scholars and aficionados of Philippine history and culture will be delighted to see several works of William Henry Scott, alongside Ileto's Pasyon and Rebolusyon. Those of us who wish to have a deeper understanding of our contemporary socio-economic situation will appreciate the works about labor unions, a chronicle of the Communist Party of the Philippines, and number of reflections about the ramifications of globalization and neoliberal capitalism in the Philippines.

As an anthropologist, I was thrilled to see various ethnographic works, and I got myself two of theme: Kale Fajardo's Filipino Crosscurrents: Oceanographies of Seafaring, Masculinities, and Globalisation and Bruno Bottignolo's Celebrations with the Sun: An Overview of Religious Phenomenon among the Badjaos. There were also narratives of displacement among the Aetas in the wake of Mt. Pinatubo's eruption, among many others. Also interesting were local histories, such as Nita Berthelsen's The Tayabas Chronicles, Reynaldo Ileto's Maguindanao 1860-1888, and Warren's The Sulu Zone 1768-1898. What I planned to be a quick stop turned to be an hour-long bibliographic adventure!

The literature section, on the second floor, is equally impressive, and is arranged according to genre: novels, short stories, poems, plays, nonfiction, among others. Even Filipino comics are on display. For any lover of Philippine culture it is truly a joy to see all those books - from Jose Garcia Villa's poems to the short stories of Butch Dalisay and even Romi Garduce's account of his Seven Summits adventures.

Finally, there are coffee table books about Baguio City, among Filipino art, architecture, weaving, pottery, and many others. Wherever your interests lie, there is surely a gem waiting to be found! Most of the books are priced around 500 pesos, but there are good bargains too, with some short story collections at 100 or even 50 pesos apiece.

Aside from the extensive collection are books about our neighbors in Southeast Asia. There's a book called "The Rice Birds: Folktales from Thailand" and in the same shelf there's "Fishing, Hunting, and Headhunting in the Former Culture of the Ngaju Dayak in Central Kalimantan"! These books are rare, and are unfortunately "exotic" in the reality of our cultural disconnect with our geographic neighbours. So it is another epiphany to see them in that bookshop in Baguio.

***

To a certain extent, bookstores are revelatory of culture, and one only needs to go to National Bookstore or Fully Booked to see how “Westernized” our sensibilities are, with Stephenie Meyer, E. L. James, and Paulo Coelho gracing the entrance while our great writers, such as Nick Joaquin and F. Sionil Jose, are relegated to the peripheries.

Which is why Mt. Cloud Bookshop is refreshing change. Far from marginal, books about the Philippines and by Filipino authors take (their rightful) centre stage. Like a passing cloud that invites introspection, these books make us look within, and can teach us many things about our beautiful culture, our beautiful land.

Baguio City
January 20, 2015

Books about the Philippines take centre stage in Mt. Cloud bookshop in Baguio

Sunday, January 18, 2015

Pope Francis’ mass in Luneta and the Filipino fear of rain

by Gideon Lasco, MD

The estimated six million Filipinos who flocked to Luneta today to see Pope Francis and attend his final mass in his Philippine visit will surely make headlines as the largest papal gathering in history. But what makes it more remarkable is that Typhoon 'Amang' notwithstanding, Filipinos still came by the millions. This, despite our tendency, for health reasons, to shy away from the rain.

Since time immemorial, rain has been seen as a cause of illness in the Philippines, and hence avoided, whenever possible. Prof. Michael Tan (2008) writes:
We do have a morbid fear of rain, thinking it causes respiratory ailments. Medically speaking, there is no basis for this belief but even physicians have been known to bring out their thick medical books to cover their heads when it begins to shower. The rainy season does result it more colds, not because of the rains but because people tend to crowd together when they seek shelter from the rain…sometimes still clutching the wet books and newspapers they used to cover their heads.
In the clinics, we doctors see this belief being articulated by mothers, who would often blame their children's colds and coughs because they were "naulanan" (got caught in the rain) or even just "naambunan" (got caught in light rain). Patients of all ages might begin their illness narrative by saying that "it all started when it rained last week..."

Outside the clinics, we see this belief manifesting in the way people respond to rain: the use of umbrellas even when it's just 'ambon' (light rain) or even though it's just a very short distance from the car to the door. It is not unusual for people to cancel or postpone events, or defer their plans for the day, because of the rain.

F. Landa Jocano frames this belief within the "hot and cold syndrome" which is a "binary system of opposition that is one of the most important conceptual frames of reference in understanding the man-nature relationship'" (2003:61). In other words, in Filipino folk medicine, many illnesses are explained in terms of the body's exposure to "hot" and "cold". Rains and winds are considered cold. Given this context, he says that the back (likod)
is especially sensitive to the cold. Thus, an overexposure of this part of the body to rain, cold wind, draft, cold water (as among the fishermen), and other similar elements of nature brings about chest cramps, known as punted, colds (sipon), tuberculosis, asthma; pneumonia, and other physical infirmities (2003: 66-67).
It is not just the back that is vulnerable to the cold elements. The bumbunan or the crown of the head is also seen as prone to the intrusion of lamig or cold. This belief likely draws from the fact that the bumbunan - or anatomically, the bregma, remains soft during infancy as the anterior fontanelle, closing only after 36 months. This explains why some people would shield their head from the rain, never mind the rest of the body.

Of course, not everyone holds these beliefs about rain. Personally, I've always defied by mother's admonitions to always bring an umbrella. And, more broadly, rain itself is not just viewed as a bringer of illness, but also a sign of blessing. Greeted by rain as I was about to climb a mountain in Zambales, an Aeta man told me that rain is heaven's way of welcoming a visitor.

But what does the Papal Mass show us, in light of the long-held beliefs that link rain and illness? Two things come to my mind:

First, our relationship with nature - rain, wind, flood, typhoon - continues to define our experiences as individuals and as a nation. It was a typhoon that brought the Pope to the country, and it was another typhoon that came upon us during his visit. That this new typhoon, Amang, comes this early in the year hints at changing weather patterns that we have to deal with in the years to come.

Second, the Papal Mass shows us that many Filipinos can overcome this fear of rain for the sake of something they deem important. In Philippine media today and in the days to come, discourses will doubtless not miss the fact that the Filipinos came in spite of the rain; and that the Pope, too, braved the rain and the typhoon. There will be personal accounts of pilgrims, including the elderly and children, who have endured several hours of rain but found such an ordeal to be worth it, with the fleeting encounter with the Pope a just reward.

Indeed, there are events and commitments that we simply cannot afford to miss, and we must not allow the rain to stop us. The tardiness, the "Filipino time", that is often blamed on bad weather can be dealt with; despite the rain, life can still go on, especially if the government is prepared. This makes me wonder: would government action, too, avert the inevitable cancellation of classes and work that punctuate every year? This would require much more than yellow raincoats - we need flood-proof roads, and better transport systems, to ensure the safety of everyone. After all, it is entirely understandable for people to be late if there is an actual flood between them and their destinations. And rains and floods pose real health threats, not least of which is leptospirosis.

But if we are to fully be liberated from the tyranny of rain and flood, we have to work for a change of attitude towards rain accompanied by the government's commitment to make it possible - and safe - for people to go about their daily lives without being threatened by the floods and the rains.

In our age of persistent typhoons and worsening floods, and of climate change to which our archipelago is particularly vulnerable, perhaps the Pope has given us another timely lesson: Rain is not something to fear, but something we can overcome.

Manila
January 18, 2015

REFERENCES

Jocano, F. L. (2003). Folk medicine in a Philippine municipality. PUNLAD Research House.

Tan, M. L. (2008). Revisiting usog, pasma, kulam. UP Press. 

Tuesday, January 13, 2015

Thou shall not eat: An overview of the relationships between food and religion

By Gideon Lasco, MD

BACKGROUND
The anthropology of food and religion can be organized into two major domains: food in religion and religion in food.  In this paper, we focus on the latter: religion in food, or how religions and belief systems have played a role in determining what we eat, who eats what, how we eat.

There are two main approaches in nutritional anthropology, the materialist perspective and the idealist (Harris, 1970). As this paper aims to provide an overview, perspectives from both schools of thought will be included in the discussion.

Considering the divergence of major religions, one way to present “religion in food” would be a comparative survey, that is, to discuss each of the major religions of the world, and discuss the relationship of each to food. However, considering that the orientation of anthropology is to arrive at explanations, I would aver that a more anthropologically-oriented way of presenting this topic is to look into the various relationships of religion in food, looking at religion as causal domain and food as outcome. The different religions can be then be used as illustrations for each of the relationships we identified.

Finally, this paper speculates on the future of food in terms of religion in an increasingly post-religious, secular world.

CONCEPTUAL FRAMEWORK
Given two interacting variables, food and religion, we can construct statements like this to state relationships based on the review of literature:

Religion __________ Food

And come up with some relationships:

1. Religion determines what is food (food preferences) and what isn’t (food taboos)
2. Religion dictates how we should eat and prepare food and where (food practices)
3. Religion sets limits on how much food we should eat in our everyday lives (food rationing)
4. Religion prescribes occasions for eating and avoiding food (feasting and fasting)

These relationships form the outline of our main discussion of religion in food.

RELIGION AS DEFINER OF WHAT IS FOOD AND WHAT ISN’T
Historically, religion has functioned as a definer of what can be eaten, and what cannot, and perhaps this is the major function of religion in food. The English term for the latter is taboo, which itself is derived from the Tahitian language where it means “unclean or cursed”. Other cultures have terms for both what should be eaten, and what should not, and these terms are used in the context of religion; they are essentially religious laws.

In Islam, for instance, the concept of halal and haram is rooted in the Holy Koran (Al-Jallad, 2008), on which the following verse is found:

“Forbidden unto you (for food) are carrion and blood and swine-flesh, and that which hath been dedicated unto any other than Allah, and the strangled, and the dead through beating, and the dead through falling from a height, and that which hath been killed by (the goring of) horns, and the devoured of wild beasts, saving that which ye make lawful (by the death-stroke), and that which hath been immolated unto idols.: (5:2)

This is similar to the kosher rules of Judaism, which likewise forbid the consumption of swine, most insects, and the mixing of milk and meat. These prohibitions can be traced to the commandments of Moses in two of the earliest books of the Bible, Leviticus and Deuteronomy.

Much of the discussion on Islamic and Jewish rules on food centers on, and is best illustrated the pig taboo, or the ban on what Harris calls ‘the abominable pig’ (Harris, 1970). In the traditional perspective, religion itself is the explanation; there is no need to probe beyond it (i.e. theological explanation) because it is what was ordained from time immemorial.

Mary Douglas, on the other hand, called for a symbolic, interpretive interpretation. She argued that prohibiting certain foods was a way of “carving up the natural world into the pure and the impure”, thereby creating a model for thinking about the purity of the Divine.

Regarding the pig, she said that while most animals are cloven-hoofed and cud-chewing such as the cow, the goat, or the sheep, the pig had cloven hoof but did not chew cud. This classificatory ambiguity is what she calls a "taxonomic anomaly", which she then claims as the basis for the pig taboo based on a symbolic or interpretive perspective (Douglas, 1966).

On the other hand, Marvin Harris argued for a materialist explanation of the pig taboo. He says that the environment of the Middle East makes pig raising highly inefficient. Because pork tastes good to humans, it must be proscribed religiously, otherwise, its husbandry will be maladaptive.

To raise pigs in arid, open environments requires heavy expenditure of water and supplementary food, and are thus expensive to keep and grow.  Moreover, the pigs eat what humans eat. The pig has another disadvantage: unlike sheep, goats, and cattle, it is not a ruminant. These factors make pig growing ecologically unsustainable, which favored the establishment of a religious proscription.

On the other hand, in Christian Europe, there are forests where pigs can thrive; it is a totally different environment. Therefore, you have a different attitude toward them compared with what continues to exist in the Middle East.

Of course, there is a religious explanation to the lifting of the pig taboo in Christianity:  In Peter’s vision in the book of Acts, it was revealed to him that there are no more unclean and clean animals; everything can now be eaten.

Arguments run along the same lines in trying to explain “sacred cow” in India and other Hindu nations like Nepal. At face value, as Heinricher (1981) observes, the situation seems to support an idealist perspective:

The case of India's sacred cattle is often cited by ideationalists as an example of blatant economic wastefulness in the name of spiritual satisfaction. Why else would starving people refuse to eat all of those cattle roaming the cities and clogging the highways, if not because of religious sanctions?5
In the idealist school of thought, it is "ahisma", the doctrine of non-violence towards all life that provides the basis for a religious proscription on cow slaughter and consumption, however contrary it seems against the rational choice. Ahimsa is also essentially the premise of vegetarianism, which is espoused by the two major schools of Buddhist thought. 

On the other hand, Harris and others, once again employing a materialist approach, says that it made ecological sense to have a prohibition of cow slaughter, considering the value of the cow in an agricultural society such as India, considering the amount of dung it produces, which is then used as fertilizer. Moreover, he critiques the acceptance of ‘ahimsa’ as preventing cow slaughter, saying that cow slaughter does happen, either by sins of omission or covert acts.

Moreover, “cow eating” does happen, by untouchables, or even by a growing number of Indians who embrace beef eating . Mencher (1971) writes that many urban middle-classed Hindus would admit to liking beef curry once informed that "upper caste" American like beef.

An interesting conclusion of Harris is found in the last paragraph of his article:

I have yet to encounter a flourishing religion whose food taboos make It more difficult for ordinary people to be well nourished. (79)

In other words, he is saying that at the weakest form of the materialist approach, religion may dictate foodways, but it is constrained by the nutritional needs of the people.

Christianity at large has lifted food taboos, as we explained earlier. However, various Christian sects have food rules and restrictions. The Jehovah’s witnesses, for instance, avoid eating the flesh of animals that have not been properly bled because they believe it is wrong to eat blood. Here, the role of food as “definer of group identity” comes into play. Many studies have demonstrated that food is a particularly potent symbol of personal and group identity, forming one of the foundations of both individuality and a sense of common membership in a larger, bounded group and this can very well apply to religion. (Wilk, 1999, Ohnuki-Tierney, 1993 et al).

As a final illustration of how religion has dictated food, the arrival of Christianity in the Pacific islands is attributed as the reason for the elimination of the practice of cannibalism. With the changing of people’s belief systems, cannibalism, has entered into a taboo (Hadden, 2009).

In sum, we can look at these relationships between religion and food according the materialist explanations about food taboos were enumerated by Meyer Rochow (2009):
-Food taboos for certain members of the society and to highlight special events
-Food taboos to protect human health
-Food taboos during pregnancy and food changes over the course of the menstrual cycle
-Food taboos as an ecological necessity to protect the resource
-Food taboos in order to monopolize a resource
-Food taboos as an expression of empathy
-Food taboos as a factor in group-cohesion and group-identity

On the other hand, we can follow the perspective of Mary Douglas, who called fof a more symbolic / interpretive explanation, looking at food as a function of culture, of which religion comprises a very big part.

RELIGION AND FOOD PRACTICES
Religions provide a “morality of food”, in the sense that it mandates how food is to be eaten and shared. There are religions, for instance, that emphasize sharing of foods, such as Christianity, which has plenty of references and illustrations in the Bible as regards the sharing of food.

Religion likewise provides an explanation of how food comes to us, and provides the means and the object of thanksgiving. Hence, the religious usually say a prayer of thanksgiving before each meal. Jesus Christ, in his famous “The Lord’s Prayer”, says:

Give us this day our daily bread (Matthew 6:-13; Luke 11:2-4 ESV) 

Acknowledging that food is from God makes food a ‘blessing’, a received substance, and thus, thanksgiving must be rendered unto the Giver. Highly symbolic, thus, was the episode in the Book of Exodus, when “manna from heaven” rained down the Israelites, literally food that came from heaven.

Saying ‘grace’ before a meal is not a unique feature of Christianity. In Judaism, the Birkat Hamazon is uttered, a series of blessings that take the form of a prayer after meals. The scriptural source for the requirement to say birkat hamazon is Deuteronomy 8:10 "When you have eaten and are satisfied, you shall bless the LORD your God for the good land which He gave you".

In Islam, the "Bismillah ar-Rahman, ar-Raheem", a common religious expression meaning "In the name of God, Most Gracious, Most Merciful" is uttered before a meal. There are also counterparts of saying grace in Hinduism

Finally, even in Japan where religion is not organized, and people are non-religious, people say "Itadakimasu" before a meal, which means "I humbly receive"; the status of food as blessing is still implied.

Another food practice of everyday life, upon which materialist explanations can readily be advanced, is the ritual washing of hands. This is practiced by Judaism, Islam, and many other religions.
Likewise, religions emphasize virtues that favor sharing of food, i.e. compassion, charity, kindness, and goodness. It is considered impious to throw away food; parents tell their children not to waste food, coming as it is from God. Materialists, again, would look at the sharing of food (i.e. compassion, charity kindness) as a very rational function of religion, which is to distribute resources from the rich to the poor, and to provide a social safety net by which starvation can be prevented.

RELIGION AND HOW MUCH FOOD WE SHOULD EAT
Religion does not merely regulate the quality of food (i.e. what is eaten); it also has something to say about the quantity of food (i.e. how much is eaten).
In Christianity, over-indulgence in food is known as gluttony, and many writers have commented about it. St. Gregory the Great, a doctor of the Church, described five ways by which one can commit sin of gluttony, and corresponding biblical examples for each of them (Orby, 1875):

1. Eating before the time of meals in order to satisfy the palate. Biblical example: Jonathan eating a little honey, when his father Saul commanded no food to be taken before the evening. [1Sa 14:29]

2. Seeking delicacies and better quality of food to gratify the "vile sense of taste." Biblical example: When Israelites escaping from Egypt complained, "Who shall give us flesh to eat ? We remember the fish which we did eat in Egypt freely ; the cucumbers and the melons, and the leeks and the onions and the garlic," God rained fowls for them to eat but punished them 500 years later.[Num 11:4]

3. Seeking after sauces and seasonings for the enjoyment of the palate. Biblical example: Two sons of Eli the high priest made the sacrificial meat to be cooked in one manner rather than another. They were met with death.[1Sa 4:11]

4. Exceeding the necessary amount of food. Biblical example: One of the sins of Sodom was "fullness of bread."[Eze 16:49]

5. Taking food with too much eagerness, even when eating the proper amount, and even if the food is not luxurious.Biblical example: Esau selling his birthright for ordinary food of bread and pottage of lentils. His punishment was that the "profane person . . . who, for a morsel of meat sold his birthright," we learn that " he found no place for repentance, though he sought it

To recapitulate, St Gregory the Great said that one may succumb to the sin of gluttony by: 1. Time (when); 2. Quality; 3. Stimulants; 4. Quantity; 5. Eagerness

Most other religions frown on over-indulgence; there are many verses in the Koran condemning gluttony, and eastern religions that emphasize penance and asceticism are doubtless disapproving of behaviors.

In sum, religions set a limit of what is the acceptable amount of eating. Juxtaposing this limit with the virtues of generosity, giving, and kindness, it is easy to see how materialists can explain gluttony as sin: such an injunction favors the distribution of excess food among the people who do not have access to it.

On the other hand, there is also much symbolism in religious passages that make for plausible parallels with food, to the extent that it will also be easy to offer an idealist explanation on how food is regulated in terms of its quantity. As nourisher of our physical bodies, food is metaphor for material pleasures, and the ability to control our diets is seen as a sign of religious discipline.

FEASTING AND FASTING
In the first three arguments, we have discussed how religion affects the food of everyday life (what, how, and how much). On the other hand, religion has produced special occasions, and food is essentially the medium by which these occasions are celebrated or performed (i.e. when to eat a lot). These occasions are called feasts. It can be averred that most, if not all religions have feasts. On the other hand, the withholding of food is likewise a religious act, often commendable, and it is called fast (i.e. when not to eat). As regards feasts, Twiss (2008) introduces her subject:

Feasting is a universal human phenomenon. It is powerful and often transformative; through feasting, social identities are both enacted and altered, political competitions are undertaken, and ideologies are inculcated. Feasting can play a key role in constructing and validating social norms by valorizing innovative materials, concepts, and practices.

We see these food practices prominently in Christianity, where, as Bynum (1985) avers, “feasting and fasting are at the heart of the Christian tradition.” In Christianity, the major feast of Christmas is a time of celebration in many countries, accompanied with an abundance of food. In the Philippines, for instance, the Christmas season is at least a weeks-long festivity, heralded with numerous “Christmas parties”, a noche buena on Christmas eve and a media noche on New Year’s Eve.

In Islam, the Ramadan is a whole month of fasting, followed by a day of feasting, the Eid al Fitr.
Materialist explanations of feasts include the creation of opportunities to distribute proteins and other essential foods. For instance, Diskin (1978) and Greenberg (1981) have suggested that high-quality protein and vitamin-rich foods distributed during the cycles of festivals in the rural Mexican villages they studied may make substantial contributions to the diets of poor participants. Furthermore, the timing of the festivals seems to have been such that food distribution took place during periods when the population was most in need of protein and nutrients.

Other anthropologists trace feasts as occasions of thanking the gods and divine forces for harvest, with the hope of an abundant year to come. Also, the many social functions of a feast are well described in anthropological literature; they are “central arenas of social action that have had a profound impact on the course of historical transformations...they articulate and inculcate existing social categories, such as status, power, gender, and age.” (Dietler and Hayden, 2001). Still, some archaeologists suggest that feasting, with its emphasis on the consumption of large animals, may have actually contributed to the domestication of animals (Twiss, 2008).

Fasting, on the other hand, is invested with much symbolic meaning, but rational explanations have included the health benefits of caloric restriction. Moreover, some studies have looked into the health benefits of specific religious practices. For instamce, Sarri (2001) found that adherence to Greek Orthodox fasting periods contributes to an improvement in the blood lipid profile, including a decrease in total and LDL cholesterol, and a decrease in the LDL to HDL cholesterol ratio.

POSTSCRIPT: RELIGION IN FOOD IN A SECULAR, MODERN WORLD
Even with the apparent decline of religion as the dominant force in society, its roles on food has, in some ways persisted. “Food is the last bastion of culture” and perhaps this can be said too of religion. On the other hand, religion has been supplanted in some ways by other forces, such as medicine and the government.

 For instance, it can be seen that biomedicine has taken over religion as the prescriber of which foods to eat and which to avoid. Gluttony may have been dangerous to your soul, but today, obesity is dangerous to your health. The Bible cautions against drinking too much alcohol, but today it is the government that requires the placement of “drink moderately” on advertisements. Vegetarianism, once a religious decision, is now motivated by numerous health reasons.

Some aspects of religion in food, however, have been strengthened by other institutions. For instance, by explaining the health reasons for some religious proscriptions, they can be reinforced, such as the washing of hands. Also, governments with a sizeable Muslim population have actually standardized and regulated halal foods by establishing regulatory bodies. In the Philippines, the Islamic Da’wah Council of the Philippines, Inc., (IDCP) is the duly recognized Halal Certification and Accreditation Authority under G.R. No. 153888 dated July 09, 2003.

On the other hand, what began as religious institutions have become secularized, or are now used in non-religious contexts. Hunger strikes, for instance, are political acts that remain a potent weapon used by activists, most famously Mahatma Gandhi, and its power can be traced to its spiritual significance. Likewise, religious feasts are now celebrated as purely secular events. In the Philippines, this is seen in the Christmas holiday season, which is arguably the season during which the most amount (and variety) of food is consumed in the Philippines. A critical approach to Christmas would look at how politico-economic structures, such as commercial institutions, have helped perpetuate this tradition.

On a final note, the technological advances of the modern age is creating “new foods”, and it is interesting how the acceptance of these foods can still be seen in terms of religious proscriptions. It can be said that there is a “taboo on genetically modified foods”, and in spite of the advantages, the popular opposition against them remains strong and can we not harken back to Mary Douglas’ words and call these foods “taxonomic anomalies”? Indeed, nutritional anthropology is needed, more than ever, in light of these emerging issues.

CONCLUSION
In this paper, we have discussed how religion has shaped what we eat, how we eat, how much we eat, and when we eat more (and when we do not eat). Understanding food practices, that is, nutritional anthropology, must always involve an understanding of the various religions of a certain society. For as long as humans eat, food will be inextricably linked with religion, mediator and mediated by it, and even where the influence of religion has waned, we will always be told that we ought to eat, and for whenever and whatever we ought not to eat, and the voice will not be too far that says: “Thou shall not eat.”

REFERENCES
Bynum C (1985). Fast, Feast, and Flesh: The Religious Significance of Food to Medieval Women Representations No. 11 (Summer, 1985), pp. 1-25 University of California Press

Dietler and Hayden (2001). Digesting the feast—good to eat, good to drink, good to think: an introduction ,in: M. Dietler, B. Hayden (Eds.), Feasts: Archaeological and Ethnographic Perspectives on Food, Politics, and PowerSmithsonian Institution Press, Washington, D.C (2001), pp. 1–22

Diskin, M. (1978). Discussion. Symposium on Mexican Food Systems. 77th annual meeting of the American Anthropological Association, Los Angeles, Calif.

Douglas M (1966). Purity and Danger: An Analysis of Concepts of Pollution and Taboo. Routledge and Keegan Paul pp. 50-61

Greenberg, J.( 1981). Santiago's Sword. University of California Press, Berkeley, Calif.

Hadden, R. (2009) Food culture in the Pacific Islands.  Greenwood Publishing House, USA. pp. 25-35

Harris M (1988). Good to Eat: Riddles of Food and Culture

Mencher, Joan (1971) Comments on Alan Heston's 'An Approach to the Sacred Cow of India.' Current Anthropology 12:202-204.

Ohnuki-Tierney, Emiko (1993). Rice as Self: Japanese Identities through Time. Princeton: Princeton University Press, 1993.

Sarri et al (2003). Effects of Greek Orthodox Christian church fasting on serum lipids and obesity. BMC Public Health 2003, 3:16

Sunday, January 11, 2015

Mountains as medicine: Hiking for health and wellness

Hikers in action in Mt. Cinco Picos, Zambales, Philippines
By Gideon Lasco, MD

Note: This article was originally published in Health and Lifestyle Magazine Philippines, October 2013.

As a medical doctor and a mountaineer, I am convinced that climbing mountains is a perfect prescription for the sedentary, urban lifestyle that we have come to embrace in this era of modernity and convenience. It takes care of so many, oft-neglected aspects of our bodies and our lives: from physical exercise to socio-cultural awareness, all of which contribute not only to healthy individuals, but also to a healthy nation.

In our age of cars, elevators, and LRT, walking has lost its place as the fundamental means of transport. When was the last time you climbed more than two flights of stairs? But walking actually plays an important role in health. G.M. Trevelyan said it best: "I have two doctors, my left leg and my right." Hiking makes us realize that we can actually cover so much distance just by walking. This fosters an attitude within us that makes us 'walk the extra mile'.

The more footsteps we take, the less carbon footprints we make. Walking not only makes us healthy persons, it also contributes to a healthy environment. I think it will also help decongest the traffic in our roads when people begin to consider their feet as a means of transport, especially in urban centers where everything is close by.

Of course, hiking is not just walking: it activates other muscle groups, too, not just the lower limbs: the upper and lower back carries your pack; the shoulders assist in balance and helps lift you when the trail becomes steeper. Some studies have demonstrated that hiking helps in the prevention of osteoporosis by strengthening the bones in your back. The more muscle groups are mobilized, the better the exercise, and by this measure, lhiking is a great fitness activity.

Finally, as an aerobic activity, hiking improves our lungs, our heart, our blood circulation. It burns calories, especially if you complement it with other activities like jogging or swimming.

Now, let us go to the mental health benefits. When was the last time you had a full breath of fresh mountain air? When was the last time you heard the sounds of the forests, far from the noise of the city? Hiking may be physically exhausting, but it is mentally relaxing, because it brings us back to nature, where our species used to belong. When I was a medical student, I found out that I actually felt better after a hike, even if I just came from a 24-hour duty! . In the mountains, 'physical exhaustion' can be a very fulfilling feeling. Doesn't it feel great to sweat out your body? Bear in mind too that the mountain is not a treadmill where the best view you can see is a LCD screen. The mountains are beautiful!

At this point, you may ask: "This is all nice and good, but I am no athlete." Is hiking really for everyone? The answer is a big YES! In fact, hiking itself brings us to the realization of how much we can do as human beings. it gives us confidence to do our goals in life. In 2009, our fraternity of medical students - the Mu Sigma Phi - accompanied amputees on top of Mt. Batulao in Batangas. Though they had to push their selves to the limit, they became emotional when they reached the summit. "I made it! I can actually do things like this!" one of the exclaimed.

In this way, hiking is also great for our spiritual health because it molds not just our bodies, but also our character. Perseverance, patience, confidence, camaraderie, courage, faith: these are courses you take at the university of the mountains. Presence of mind, too: and this is a valuable asset in an increasingly uncertain world. When the storms and floods come, a hiker is always prepared. Finally, when we dream of high mountains but realize that we have to start with the low ones first, we appreciate the value of discipline and humility, and we allow ourselves to learn from others ahead of us.

Earlier, I said that discovering the outdoors can help us build a healthier nation. I say this because of the social, cultural, and environmental awareness that climbing mountains bring. Mountains are not just habitats for wildlife; they are also homes for our many of our fellow Filipinos. By encountering them in their ways of life and the struggles they face, we become more concerned and connected to them. We cannot love that which we do not know, and by going there - in the hinterlands of our country, beyond the watchful eye of mass media - we see, we learn, and we begin to empathize.

If you have heard the sound of falling trees, you feel illegal logging and become more empowered to speak about it. If you have heard stories of indigenous peoples and their poverty, you become inspired to be their voice. When social issues become more real, calls to action - and change - are not far away.

There is so much more that mountains have to offer. It is up to you to discover what the mountains can mean in your life. For some, it is an escape, for others, it is a pursuit. Some people climb to challenge themselves, others climb to relax themselves. Others look ahead to the summit and the triumph it represents; others look around the trails and the beauty it reveals. For families, couples, and friends, it is a great bonding activity where we are away from the distractions and stresses of life, allowing us to focus on building relationships. With all its benefits, I can sincerely say that hiking will take you up but it will never let you down.

What are you waiting for? See you on the trails!

Amsterdam, The Netherlands
October 2013

“Illness” and “disease” in the Philippines

Doctor-patient interaction in a medical mission
in Puerto Princesa, Philippines
By Gideon Lasco, MD

IN THE FUTURE, we will have more illnesses without a disease, and more diseases without an illness. There are many reasons to believe that this will happen in the Philippines. There will be more illnesses without a disease as the gap between the explanatory power of Western medicine and the health-related experiences of the population continues to grow. On the other hand, there will be more diseases without an illness due to the increasing medicalization of the mundane - the classification of the common that, while expanding the realm of medicine to the everyday, fails to account for the breadth and the scope of human experiences. These trends are better understood in the context of health systems: in any society, there is a dominant health system, in our case Western medicine, which is the “disease-labeling authority”. Other health systems exist, offering alternative disease labels. These alternative systems likewise offer competing “illness explanation”, providing “explanatory models” for particular experiences of a patient or a community.

Why is there a distinction between disease and illness in the first place? Medical anthropologist Arthur Kleinman makes the following contrast between the two concepts: “A key axiom in medical anthropology is the dichotomy between two aspects of sickness: disease and illness. Disease refers to a malfunctioning of biological and/or psychological processes, while the term illness refers to the psychosocial experience and meaning of perceived disease. “ (1981:72)

This distinction is important because it is an acknowledgment that the patient and the physician apprehends two different realities; illness is what the patient experiences; disease is the label or classification that the physicians ascribes to those illness, based on their interaction. An illness can bring forth many diseases: what a patient is subjectively feeling (hand tremors) can be a Western disease (i.e. neuropathy) and a folk disease (i.e. pasma). On the other hand a single disease label such as community-acquired pneumonia can also bring forth many illnesses (i.e. ubo, pilay-hangin, hirap huminga).

Disease has been equated to its western bio-medical definition and illness is identified with the local indigenous knowledge (Fabrega Jr, 1972; Young 1982), but it is an interesting exercise to apply the same distinction between personal illness and folk disease. In the context of the illness-disease dichotomy, I find the term “folk illness” problematic, as indigenous medicine has its own set of classifications too, and just like Western medicine, it may or may not fit the “illness” experience of the individual. The interchangeability, and close approximation, of folk and individual illness is a consequence of the nearness-of-fit between these two distinctive labels. The folk disease / concept of “ubo” is so successful in defining the illness experience of a Filipino experiencing cough that it is adopted by the individual to describe what he feels.

Thus, the non-difference between illness and folk disease is understandable.  Western medicine, on the other hand, has the unique position of creating a palpable distinction between disease and illness, because it has gone beyond sensory observation (i.e. palpation, inspection) to the unseen yet mighty diagnostic tools of microbiology, biochemistry, and radiology. Psychiatry, too, has constructed an architecture of disease that is far divorced from what the layman assigns to particular conditions.  Yet for all the taxonomic complexity of disease nomenclature, for all the criteria that have been assembled to define them, Western medicine is non-absolute, and is imperfect in its objectivity: disease itself is a relative term, shaped by a plethora of factors – proof of this are the changing definitions of many a condition, including many psychiatric conditions, medical conditions, and the evolution of “new” diseases such as obesity and osteoporosis. Yet, it is much more rigid and objective than illness, and for the purposes of discussion, it is useful to see it as absolute and objective relative to its more relative, subjective counterpart.

Again, to summarize: illness is what the patient experiences; disease is the label the dominant health system uses to “code” what the patient experiences as part of disease taxonomy and nomenclature. Although the illness-disease dichotomy may be applied to other health systems vis-à-vis the patient’s experiences, it is more prudent to restrict our discussion of it as being a good model in describing what we experience today in our society.

If we accept the aforementioned definitions of disease and illness, the “fit” between illness and disease may be construed as a measure of the success of the dominant health system to account to health experiences of the individual patient and the community.  Corollary to this, the prevalence of disease without an illness, if ever we will come to a point when we will actually measure these things, may be construed as an index of weakness in the health system. Let us go further and use politics as metaphor: Western medicine, as the government of health, only has jurisdiction over diseases, and therefore illnesses without a disease are alienated, stateless. While Western medicine itself is not a single entity, throughout the discussion I will deliberately personify it, both to simplify the discussion, and to articulate the hope that it would act as if it were a single entity, able to identify its shortcomings and act on them.

Having explained the context of diseases and illnesses amidst co-existing health systems, let us proceed with four speculations:

1. In the future, we will have illnesses without a disease as long as Western medicine ignores, and fails to account for, the “folk illnesses” and the “psychological lang yan”. 

My mother, a very healthy, vigorous fifty-year old woman, has been feeling a vague syndrome of headache, chest pains, weakness, and stomachache since a year ago, and as the family doctor, I have struggled to identify the disease behind this illness. It came to a point that a suspicious ECG reading forced me (and her) to rush to Asian Hospital from our house in Laguna, fearing that it the chest pains might be cardiac. Yet, all the laboratory results came out to be negative. The topnotch cardiologist declared it to be a gastrointestinal problem, likely GERD, but three weeks of treatment was futile; once, while I was abroad, my mom was even duped into taking a full liver and Hepatitis profile, costing thousands but revealing nothing. Until now, she experiences the symptoms, but there has yet to be a diagnosis that can string everything together.

Could it be a folk illness? Probably, a traditional healer will at least come up with a diagnosis, but my mother does not believe in traditional healers so consulting them is out of the question.

Could be it be fall under the category of “it may just be psychological” or “it’s psychogenic”? There is a powerful temptation among us doctors to dismiss as “psychological” things we do not know, but the patient’s reality, not our own, defines what an “illness” is, and if we fail to address it, we have neither healed nor given comfort. Illness, after all, is “no less real” than disease (Pool; 48). Again, this is an area of weakness, and for Western medicine to be truly a “medicine for the people” it must recognize that these areas are real, and conditions that cannot be classified, no matter how "petty" in our clinical view, deserve to be studied. Unfortunately, little attention is focused on the mundane conditions that afflict most of humaniy: back pain, headache, weakness – as a young doctor almost every week someone complains to me of these symptoms but I have to admit that I am not adroit in dealing with these seemingly facile conditions, partly because they were not emphasized in medical school.

Indeed, my experiences with family and patients alike show that in real life, symptoms in real people differ from the expected symptoms we find in the textbooks; and thus so many people have illnesses that cannot be classified, or defined in terms of disease. Since Western medicine cannot offer an explanation, patients turn to alternate health systems who offer the two functions of a health system: to heal and to explain. Whether or not they are successful in these functions is beside the point; at least they offer something, even if this offer comes with the desire for financial gain. In the Philippines, this speculation can lead us to expect the rise of “Traditional medicine clinics” and “Alternative medicine clinics” – a trend I already see in big cities in Mindanao and Visayas. In Davao, for example, there are prominent advertisements of the clinic of “Dok Alternatibo”, who even has a radio program that answers people’s questions.

The solution, of course is for Western medicine to check the premises upon which its construction of disease is built; it must be more inclusive, more dynamic, and, whenever it is imposed upon a host culture apart from its parent culture (i.e. American culture; British culture), it must also take into consideration the health beliefs of the people.

2. In the future, we will have more diseases without an illness as medicine becomes more specialized.

When pathology goes beyond symptomatology; i.e. when doctors are able to see something wrong even when the patient does not, diseases come to existence without a corresponding illness. But then, the very act of diagnosing a disease almost always generates a disturbance upon a person, such that a proposition might be advanced that no disease is without illness; the very act of diagnosis, while at times therapeutic, is also pathogenic (i.e. illness-generating) for it generates, at the least, anxiety, and at the worst, stigma.

This will become more significant in the future, as doctors’ ability to probe beyond what can be experienced grows more powerful. Tumors used to be detected by inspection and palpation; now, they are detected even before they are felt, by the means of x-rays. This is, at face value, a very positive development: early detection of breast cancer is life-saving. Yet, there are also challenges: It is now possible for a woman to suddenly undergo life-changing treatment (i.e. mastectomy) for a condition that she didn’t even know she had. Thus, more than ever before, Western medicine demands faith from its constituents - faith enough to believe the diagnosis and faith enough to accept and actually undergo the treatment prescribed.

Technology is not the only driver towards this trend; defensive medicine is also contributory; as doctors in the United States and elsewhere try to protect themselves from negligence by overdiagnosis. In order to It can be argued that another, related driver is commercialization of medicine, which favors the establishment of diseases where there are none, for these novel diseases, even if they are without illness, necessitate drug therapy. An example is osteoporosis, a “weakening of the bones” diagnosed solely by a diagnostic test. In Overdosed America, medical doctor John Abramson traces the popularization of osteoporosis and links it with the development of certain bone-density-modulating drugs. He concludes that normal aging (which naturally results in decreased bone density) has been medicalized. And, to exacerbate matters, this disease without an illness can potentially create actual disease with illness – by way of side effects of anti-osteoporosis drugs. Ultimately, the patient suffers and he or she loses trust in the health system.

Another problem with these “diseases without illness” is that they are also areas where alternative health systems can make the offensive, oftentimes with the intent to make profit. The easiest illness to treat is that which does not exist, at least on the surface; it is easy to make patients believe that their breast cancer is gone when they never felt it to begin with. Moreover, diagnostic tests employed by alternative medicine practitioners, such as “nutritional microscopy” and “urine analysis” rides on the power of Western medicine to pronounce diseases even without symptoms, and makes its own “diseases”, after which they make their own “cure”. Indeed, the very existence of diseases without illness implies that it is no longer possible for patients to verify their own health and wellness; and with this “oversight on one’s body” lost, patients become more vulnerable to other sources of “authority”.

These examples make the point that diseases with illness are also a good indicator of what to watch out for as we guard ourselves against opportunistic health systems (and individuals) who wish to make a profit from this area of vulnerability. Western medicine must adequately explain and justify the benefits of making diseases without illness; it must present itself as trustworthy; it must not abuse and it must not let others abuse this unique position of declaring what goes on inside a human body unilaterally (i.e. not requiring the validation of the person himself).

There is a very special case of disease without illness – and a most compelling example of such: diseases of the future. The diagnosis of future diseases is a very important scenario that will become more of a reality as genetic testing comes of age; long before the disease manifests, it has already been prophesied by genetics. A predilection for cancer can be established at birth, and long before the cancer actually manifests (if at all it manifests), it would have already produced anxiety, fear, and stigma. So powerful and so real is the impact of this eventuality that the United States, in 2008, passed the Genetic Information Nondiscrimination Act, which forbids group health plans and health insurers from denying coverage to a healthy individual or charging that person higher premiums based solely on a genetic predisposition to developing a disease in the future. The legislation also bars employers from using individuals’ genetic information when making hiring, firing, job placement, or promotion decisions. This act acknowledges that diseases of the future as a disease without illness which becomes an illness without disease as the patient reacts negatively to what might befall him or her.

3. Wellness without health is the inverse of illness without disease and we will see this more as wellness becomes commercialized.

In his textbook Medical Anthropology, Pool states that there “parallel to the distinction between illness and disease, a similar distinction can be made between cure and healing.” (2005:53) This parallel, inverse concept can be related to the trend of “wellness” which we see today and which I speculate will be much bigger in the future. The introduction of a variety of supplements, fad diets, and various therapies – from physical to metaphysical – all propose to “heal” and achieve “wellness”.

There is, of course, great commercial interest in making people embrace this kind of wellness. Yet, their vulnerability to this promise of better health can be traced to Western medicine’s shortcoming in explaining to its constituency what it means to be healthy, and what is the proper way to achieve wellness and health. Indeed, the explanatory responsibility of Western medicine is not only limited to the need to account for all illnesses as diseases; there is also the need to define wellness as health. There is a need to make sure that “wellness” really translates to health, even as the state of wellness, independent of physical basis, can also be produced. Our concern here is that pursuit of wellness that does not lead to health (i.e. intake of worthless supplements) has an opportunity cost, taking away time and money that could have been devoted to better activities that actually lead to better health.
I would like to reiterate that areas where claims of wellness are allowed to be made without real health indicate the failure of Western medicine to communicate achievement of true health and wellness. In the area of boys’ height, for instance, the fact that a food supplement claiming to make kids taller is thriving on the market means that there is inadequate knowledge about the physiology of growth. Other inadequacies in the health system come up here, including poor regulation by government agencies.

4. In the future, diseases without an illness would become illnesses without a disease. 

Who is the sanctioned pronouncer of “disease”? The democratization of information – manifest most latently in the Internet – has enabled laypersons to diagnose themselves, potentially creating for themselves diseases without illness, which then become illnesses without disease, as worry sets in, then panic, then despair.

This is what we see now, as medical information becomes readily available in the Internet. With Kalusugan.PH, my project to bring health information to a wider Filipino audience, I can attest to the fact that a lot of Fillipinos are searching for diseases directly. Sexually-transmitted diseases are particularly searched, likely because there is no other way to access this information.

Again, this interaction between disease and illness creates a vulnerability; there is a lack of explanation, and if an unscrupulous third party offers it, even for a price, it might be taken out of desperation. Health information then becomes a commodity, regardless of the ramifications of its being in the hands of those who do not necessarily know how to process it. The most direct consequence may be anxiety for those who are diagnose themselves with a disease that they don’t have in the first place – this then turns to illness without a disease, the cure of which is simple reassurance from a doctor. Also, third parties can mislead these patients by providing wrong or inaccurate information.

Indeed, this is one important challenge for Western medicine: to empower patients; to make information available for patients but at the same time make doctors available to patients to explain and interpret this information, as needed. Against the much more accessible and affordable Internet, doctors may retain their dominance if they demonstrate somehow that they alone can offer: competence with compassion, reassurance without judgment, objectivity with trust.

The Internet is not the only source of this concern: mass media, including TV and radio talk shows featuring doctors, can also inadvertently cause people to diagnose themselves. Health information may also diffuse vertically in hospital structures, and nurses and health professionals (there are lots of them right now) may also decide to “play doctor” and make pronouncements of disease.

The solution here is very clear: health care must be accessible and affordable to begin with; without money, patients are left with no choice but to turn to other sources of health information. But with doctors readily available and affordable, there will be little impetus to resort to others. The issues that arise with the democratization of health information can be solved by the democratization of health care itself. These thought experiments on illness and disease can go on and on; Kleinman (1981) affirms this, saying that there is a circular relationship between illness and disease.  We need not belabor the point as I believe that our case has been established with these four illustrations.

CONCLUSION
The disjunction between illnesses and diseases point of areas of vulnerability where there are gaps between patient experience and physician knowledge. This is one role which medical anthropology plays, and ought to play, on health policy: in a drive to improve the capacity of our modern health care to heal, we must not lose track of the explanatory role of medicine, which, if not achieved, can lead to illness. While illness and disease are different, their net effect is similar: patient suffering, whether anxiety, pain, unnecessary loss of time or income – stomachache by any other name will hurt as badly. By striving to create a correspondence between illness and disease (i.e. a biopsychosocial approach), we reduce these areas of vulnerability, therefore enhancing clinical care and overall health of a population. Helman (1980) concludes: “For medical care to be most effective-and acceptable to patients, practitioners should treat both illness and disease in their patients at the same time.” Going back to our model of Western medicine being the dominant health system, we can paraphrase Helman and say: “For Western medicine to maintain its incumbency as the dominant health system, it must listen to its constituents”.  And perhaps add: “Or else, other models will prey on its constituents, leading to dire health consequences.”

Whereas the approximation of illness and disease was seen as an indicator of improvement in the health system, our speculations point to an exacerbation in this disjunction in the future, brought about by an interplay of numerous factors, including the growth of commercial interests (i.e. the nutriceutical and the pharmaceutical industries), the trend towards defensive medicine, the persistence of medicine’s negative, condescending attitude towards cultural beliefs, as well as advances in medical technology like genetics and diagnostics and other technological advances such as the Internet.

The dynamics of illness and disease is likely to become more interesting as the trends we articulated unfold in the near future.

Manila
June 2011

SELECTED BIBLIOGRAPHY

Abramson, John: Overdosed America: The Broken Promise of American Medicine. HarperCollins Publishers, 2004.

Fabrega, Jr. H.: Medical anthropology. pp. 167-229. In: Biennial Review of Anthropology. B.J. Siegel (Ed.).Stanford University Press, Stanford, 1972.

Helman, Cecil: Disease versus illness in general practice. pp. 548-552. Journal of the Royal College of General Practitioners, Sept. 1981.

Kleinman, Arhur: Patients and Healers in the Context of Culture. pp. 56-80 University of California Press, 1981.

Pool. Medical Anthropology. pp. 40-55. Open University Press, 2005

Young, Allan: The Anthropology of illness and sickness. pp. 1205-1210 Annual Review of Anthropology, 1982.

Wednesday, January 7, 2015

Kulam (sorcery) in different anthropological lenses

by Gideon Lasco, MD

Kulam (sorcery) is an oft-encountered institution in many Filipino communities. Evans-Pritchard makes the classic distinction between witchcraft (asuwang in Tagalog) and sorcery by suggesting that the power of the sorcerer (mangkukulam; mangbabarang) lies in the use of medicines, rituals, and spells while the power of the witch is an ‘inherent quality’ (Evans-Pritchard, 1937:21).

Anthropology offers different lenses through which we can understand the phenomenon of kulam:

Classical evolutionism, which places societies in different stages of development but on a linear track, would look at kulam as belonging to the realm of supernatural beliefs and it would classify such belief with those of other cultures holding the same belief, in keeping with its comparative methodology. In his Primitive Culture, for instance, Tylor devotes much attention to various supernatural beliefs of ‘lower cultures’ (Morgan, 1877:120-145), explaining them as attempts to explain life and death. Building on Tylor’s ideas, James Frazer compared religions and belief systems around the world and concluded that there are three progressive stages of human belief: primitive magic, religion, and science. The idea of kulam would fall under ‘primitive magic’, magic described as ‘one of the earliest means by which man endeavors to adapt the agencies of nature to his needs (Frazer, 1959:469).

Culture and personality exponents, like Margaret Mead, claim that ‘culture is personality writ large’ and that ‘culture, not biology, determined human responses to life’s transitions, like adolescence’ (Evans:110). Thus, this approach would look at how aspects of culture, like folktales, enable and enact the institution of kulam. For instance, the very real fear that people experience in relation to the sorcery endows the institution with power, and perpetuates the prestige of the sorcerer. Whenever children are threatened by their parents with words like “Don’t wander at night, a mangkukulam might get you!”, these views are reinforced and ‘writ’ into the people’s personalities.

Neo-evolutionism will have a freer hand in interpreting the notion of 'kulam'. With its emphasis on historical events and materialistic explanations, one may well look at the past, including epidemiologic events and environmental circumstances. For instance, a distant village may be labelled as a village of sorcerers as part of a general fear of outsiders that is rooted in the possibility of contagion. The illnesses that sorcery can inflict – or may have inflicted in the past – may very well be symptoms of diseases like yaws or leprosy. Leslie White’s brand of neoevolutionism would also look at the roles that sorcery play, bringing him closer to functionalism, which will be the last lens we will consider.

Structural-functionalism is concerned with how the structures of a society operate (cf. Spencer’s organic analogy) and how various elements of society, including belief systems, “function” to maintain the stability of a society. With this perspective, particularly of Malinowski’s functionalism, we can approach kulam as a form of social control, a “a valid way of “punishing” individuals who have violated social norms” (Tan, 2008:14). One observation I have that makes sense in light of this view is that the kulam institution is stronger in far-flung areas like islands or distant mountain communities. Without any other means of social control – and with the government institutions too far to make any effective presence – the institution continues in the present day.

By offering various lenses to look at phenomena, medical anthropology offers us perspectives that allow us to make sense of the mysteries of our culture.

REFERENCES


Evans-Pritchard, E. (1958). 1937. Witchcraft, Oracles and Magic Among the Azande.

Frazer, J. G. (1959). The new golden bough: A new abridgment of the classic work. T. H. Gaster (Ed.). Criterion Books.

Morgan, L. H. (1877). Ancient society: or, researches in the lines of human progress from savagery, through barbarism to civilization. H. Holt.

Tan, M. L. (2008). Revisiting usog, pasma, kulam. UP Press.

Tylor, E. B. (1958). Religion in primitive culture (Vol. 2). Harper.

Making sense of "Bawal umihi dito" signs in the Philippines

by Gideon Lasco, MD

Bawal umihi dito: It is an ubiquitous injunction in urban spaces, often boldly painted onto walls, and it translates to "it is forbidden to urinate here". The audience? Filipino men, many of whom continue to take the liberty of emptying their bladders in front of walls, electric posts, and yes, jeepney tires. Go to any densely-populated nooks of the metropolis and there's no denying the pungent odor of piss, which ironically juxtaposes with the aforementioned sign, as if to affirm its relevance by its violation.

Occasionally, the sign is accompanied by the threat of fines, i.e. 500 pesos. In some cases, a municipal ordinance is even invoked, complete with penalties such as imprisonment, as if to make sure that the would-be audience will be convinced about the veracity and seriousness of the sign.

But the very existence of these signs call for some thoughts on this matter. What does it mean for our society? How does it bode for our future?

It is a masculine privilege to take a piss in a very convenient way; it is one of the most obvious gender differences a child observes as he or she grows up. The female toddler is laughed at when she pisses, which requires her to assume an inferior, I.e. squatting position. On the other hand, male children find it fun to manipulate their penises, "shooting it in the toilet bowl" when called for, among themselves; there is some experimentation, like as a contest of having the tallest, farthest stream of piss, an early exploration of sexuality. Today, "pataasan ng ihi"  it continues to be a metaphor for male rivalry. Developmentally, it precedes other forms of male contests, such as "palakihan" (having the largest penis). These things suggest that urinating is not seen as an embarrassing activity at all for many Filipino males; it may be labelled as mischievous, but it is not shameful.

It is very likely that for the longest time, nobody bothered to have male urinals, particularly in rural areas where the bare earth is still visible everywhere. After all, it only takes a few hours before the urine, and its smell, is drained by the soil.

But urbanization took place: villagers flocked to cities, and villages became cities. What was once soil was covered with cement; the open spaces became farther and farther away from people's homes. Backyards became smaller, and more people lived in lesser space.

Sanitation became a problem. Where nearby streams freely flowed through villages, carrying, in the cities, pipes and sewer systems were required, and with it, a financial cost, a need to subscribe to water. Comfort rooms, a taken-for-granted feature of modern living, became unreachable to many, especially the homeless, and those living in the slums. Those of us who have always lived with water faucets may likewise take for granted the availability of water, which in many areas have to be collected and transported to their houses. This is the origin of the term 'pila balde' - a queue of pails as they wait their turn for a fill of water. Some of those pails have come several hundred meters away, and having brought it thus far, you will not waste it just to rinse away urine.

I once had the opportunity to ask a slum dweller how she disposes of human waste considering that her houses consisted of a tiny room in a patch of iron sheets and wooden planks. "I just throw it away," she said laughingly, adding, "like a flying saucer".

There are no more open spaces in the city - save for the rivers, the lakes, and the ocean which have become the unfortunate receptacles of human waste and pollution. Of all the structures of the metropolis: the buildings, the subdivisions, the malls, the only one that is truly accessible to the general public is the street, and thus it is in the street where petty crimes happen, where money is earned in ways that skirt the boundaries between legal and illegal, and yes, it is the locus where offences such as urinating occur.

In 2003, the MMDA embarked on a program to populate the metropolis with pink urinals for men. More than a decade later, it is unclear whether this initiative have had an impact, which, given the number of men in the cities, would at best be minimal. In fact, in 2012, an INQUIRER article reports how a government audit found that, aside from millions of pesos wasted on the program, “...the purpose of procuring such urinals was not satisfactorily achieved as manifested by the foul smell coming from most of the urinals installed.” You could almost see the article's title coming: MMDA urinals leave stink in COA report. 

***

"Bawal umihi dito", as the MMDA experience shows, is not simply a numerical deficiency of toilets in our streets. It a sign that we have not fully come to terms with the urbanization of our society.  Not too ago, people lived with the bare earth and rolling streams which cleansed their environments. Alas, the habits of this bygone era persist in the city, which is a concrete jungle, where evaporation takes time and drainage takes forever.

Moreover, it is a symptom of the overcrowding of our cities, a shared adaptation to limited resources, a lack of access to water and sanitation, and the poverty of the environment.

Finally, it is an example of how people flaunt the law, how people know that not all laws are implemented, and how people who are 'madiskarte' can get away with many things in the country. It's not just Bawal umihi dito, but "Bawal tumawid dito" (you cannot cross the road here) and "Bawal magtapon ng basura" (you cannot throw away garbage) and many others that are oftentimes ignored. In this specific form of ordinance, we saw how it is permitted by cultural norms as a privilege of masculinity. I would argue that it is also enabled by a general attitude towards the law that is not helped by government officials being seen as lawbreakers, instead of lawmakers and law-abiding exemplars.

It will take more than municipal or city ordinances to cleanse the streets of putrid smell. It will take a nationwide effort to be disciplined in things large and small, a respect for the law which goes hand in hand with the respectability of the lawmakers and law enforcers, and inclusive growth that will reach the slums, the poorest of the poor. Finally, a civic consciousness should emerge that goes beyond "tapat mo linis mo" towards "tapat natin, linis natin".

Quezon City
January 7, 2015

Tuesday, January 6, 2015

Tagay: Why there's no Tagalog word for "cheers" and other notes on Filipino drinking culture

by Gideon Lasco, MD

I was with my family in a restaurant in Tagaytay, and the discussion went to wine. My brother-in-law, an American with a keen interest in Filipino culture, inquired about the Tagalog word for "cheers". To which, we couldn't come up with an answer. In social gatherings, "Cheers" is used, and in more informal settings sometimes men also use "kampay" which comes from the Japanese "kanpai"(乾杯). "We just use cheers, I guess," we replied, to his disappointment.

The question lingered in my mind, and I felt that to answer his question adequately, we need to look at Filipino drinking culture, which predates the coming of the Europeans.

When Magellan arrived in the Philippines in 1521, his and his men found alcohol being drank by the locals. Aquino and Persoon (2008:198) notes: "That the inhabitants prepared their own drinks and and were big drinkers were what the Spaniards discovered when they landed in the Visayas." Antonio Pigafetta, Magellan's chronicler, took note of the tuba, distilled wine from coconut, which he considered to be "stronger and better", comparing it to Spanish brandy (Fernandez, 2013). 

The tuba is still around, with the same process unchanged for several centuries, and so have other kinds of indigenous liquor, such as the lambanog of Batangas and Quezon, the basi of the Ilocos Region. When I went to Southern Cebu last year to climb a mountain, there was tuba available at the trailhead.

How do people drink these beverages? In what context? Drinking, as in many cultures around the world, is for celebrations, and for enacting social relationships (Heath, 1976). But what is interesting is the way liquor is drunk in the Philippines (2011:199).
Only one glass is used and a tangero (person assigned of pouring gin in the glass) is assigned. He pours out the same amount in the glass and passes it around, everyone drinking, with no one spared. The tagay ('shot') may be immediately followed by another shot of 'chaser' (water or Coca-Cola). This goes on in rotation until the supply ends or drinkers surrender or are 'dead drunk', whichever comes first.
(I must offer an addendum by saying that the tanggero doesn't always pour the same amount in the glass. When there are women in the group, he may put less, and when he wants to make someone really drunk, he puts more!) 

There are other niceties of this ritual, including offering the first portion to the ground, for the spirits. This draws on Filipino folk beliefs. There are unwritten rules, and participants are expected to join the drinking until the liquor has ran out. Finally, then there is the pulutan - the finger foods that come with the drink. I've had interesting forms of pulutan - dog meat in and raw fish in Batanes - and this ought to be an interesting topic for Nutritional Anthropology. 

Interestingly, it seems that tagay has always been part of Filipino drinking culture, as it appears in the earliest Spanish-Tagalog dictionaries. In the Miguel Ruiz vocabolario of 1630, an entry for tagay is as follows: 
La racion de vino ya echada en la escudilla que se da y deputa para uno, mana ang tagay mo: esta es tu racion o porcion de vino; Um: l. managay: repartir o dar de beber vino, o cosa que emborracha; y si. m. magtagay, an: aquien: y si. m. Pagtagayan, i. l. ipanagay.nombre: tagayan: la escudilla diputada para beber vino; Catagayan: una escudilla de vino. ff. Patagayin. y mejor. Papanagayin: a quien se manda dar de beber; y si. m. Papagtagayin, Patagayin:a quien, y si. m. Papagtagayan. ipa: l.ipapanàgay: el vino que; y si. m. ipapagtagay. sinonimos: tudyo, baric. Vide: singgàlong.
Then, as now, tagay is defined as the rationing of the liquor around the group using just one cup. Strikingly, this cup is also given a name in the same vocabulario passage, one that is familiar in street corners on Friday nights: tagayan.

Lending credence to the antiquity of this practice, the 'sharing of the glass' also figures in one of the most iconic scenes in Filipino history, the 'blood compact' between Miguel Lopez de Legaspi and Sikatuna (Katuna), where the two sealed their alliance by sandugo, means of sharing a glass of liquor mixed with their blood (see Aguilar, 2010 for an interesting discussion of the blood compact).

This, I believe, answers my brother-in-law's question. We do not say "cheers" because in our drinking culture, we do not raise our glasses and join them together, as Europeans do. This is because when we drink, there is only one glass. Thus, while we do bring our glasses together, we are joined in one glass, which is passed around in what we call 'tagay'. 

Today, beer has become a very popular drink in the country, and San Miguel Beer has become the iconic Filipino beverage. In cosmopolitan settings, so have cocktails and wines. But in much of the country, consumption of hard liquor - gin, rum, brandy, and of course tuba and lambanog - remains very high.

*** 

Whatever form the inuman takes, we do say "cheers", as we have already absorbed the word, just as we have acquired the word serbesa 'from the Spanish cerveza.  But we have a deeper idea of sharing, of coming together, which is the 'tagay', drinking with just one cup, signifying and substantiating the ties that bind us together.

Quezon City
January 7, 2015

REFERENCES

Aquino, D. M., & Persoon, G. A. (2011). TRADITION AND CHANGE: BEER CONSUMPTION IN NORTHEAST LUZON, PHILIPPINES. Liquid Bread: Beer and Brewing in Cross-Cultural Perspective, 7, 197.

Fernandez, D. G. (2013). Historias, Cronicas, Vocabularios: Some Spanish Sources for Research in Philippine Food. Budhi: A Journal of Ideas and Culture, 5(3 6.1), 259-275.

Francisco, J. (ed.) (1997). Bocabulario Tagalo by Miguel Ruiz (1630[1997]). Pulong: Ateneo de Manila University, Quezon City.

Heath, D. B. (1976). Anthropological perspectives on alcohol: An historical review. Cross-Cultural Approaches to the Study of Alcohol: An Interdisciplinary Perspective, 41-101.

Monday, January 5, 2015

Pasalubong, pabaon, utang na loob, and Marcel Mauss' notion of gift exchange

by Gideon Lasco, MD

I was in Russia with a group of Filipinos last month and on our last full day in Moscow, we devoted a big amount of time visiting the Izmailovsky Market, touted by tourist brochures as a ‘souvenir paradise’. As soon as we arrived, my friends lost no time in buying Matryoshka dolls of all sorts of styles and sizes. The ones who bought the most number are those who worked in big companies or government institutions. “Syempre pagdating mo hahanap ka nila ng kahit ano, maski keychain!” (“Of course when you get back, they’ll look for something from you, even just a keychain!”) Another companion, realizing that what she had just bought for her mother was just the price of a mineral water bottle in Moscow, said: “Nakakahiya naman, eto lang ang iuuwi ko!” (“This is so embarrassing, [if] this is all I’ll bring home!”) and she proceeded to buy a more expensive one.

We Filipinos have all sorts of gift-giving opportunities (or responsibilities). The one I described in the above illustration is the institution of pasalubong: a traveller is expected to bring back souvenirs for his family and friends. Through repetition and diffusion of ideas, the pasalubong becomes ‘ritualized’ and ‘standardized’ for particular places: for Davao, durian candy; for Baguio, a walis tambo (broom) or else peanut brittle, and for those coming abroad, chocolates, keychains, canned goods. Whenever my father goes on foreign trips, we as children were always entitled to ask for one pasalubong each.

Another institution is the pabaon, in which a visitor is given gifts in the places he visits. Whenever I visit my relatives in Negros Occidental, they would make sure that I have a box full of local delicacies to take home with me. Knowing their propensity for pabaon, I have to be careful in mentioning things that I wish to buy, or even things that I admired in their house, because they will be sure to buy it themselves - or give it to me.

Marcel Mauss in his classic The Gift says that gifts are “in theory voluntary but in fact they are given and repaid under obligation” (1990:1); attached to them are obligations both on the part of the giver and recipient, encouraging reciprocity, fostering solidarity and strengthening social ties. Gifts speak of the giver’s generosity, prestige, and wealth, and the recipient’s ability to match the giver’s good virtues.

Our gift-giving institutions can be used to support Mauss’ theory, and I can say this from an emic perspective. For the traveller who comes home, the pasalubong he brings back serves a way to attach value to particular people he missed during his time away from home. The pabaon and pasalubong becomes a vessels through which social relations can travel, and geographic and social distances are bridged.

When important favors are requested and given, another important concept comes up: that of utang na loob. Often translated as ‘debt of gratitude’, this value suggests that there are particular favours rendered that cannot be quantified or repaid in monetary terms. The only way to ‘repay’ it is to return the favour when an opportunity arises. A doctor who offers free medical consultation to a lawyer can expect free legal advice in the future. One cannot find a more Maussian example of gif exchange in the Philippines than the concept of utang na loob.

Gift-giving traditions, however, can be dysfunctional, too. I have relatives in the United States who said that the ‘enormous cost’ is hindering them from coming home to the Philippines. “But the airfares are not expensive anymore!” I countered, only to hear an interesting rebuttal: “It’s not the airfare that’s expensive, it’s having to buy pasalubongs for everyone!” Here, we see how an institution that is supposed to mediate social relations instead becomes a hindrance for them.

Then there are the gift exchanges during the Christmas season: they  are so institutionalized that it sometimes become routine and meaningless, as when picture frames and cheap wines accumulate during Christmas season. I am even hearing a new term, ‘regift’, which happens when a person who receives a gift passes it on to another person as his own gift. The spirit of gift-giving is gone; it is seen as an obligation, which people seek to fulfil as easily as cheaply as possible.

Then, of course, there is utang na loob, which enacts an allegiance on the part of the recipient to the giver, can get in the way of other allegiances, including professional ones; when utang na loob is invoked to override even national laws, it gets in the way of national progress. Dominating today are headlines about Janet Napoles, the businesswoman who is alleged to have institutionizeed corruption in the upper echelons of government. Anecdotes about a senator being given a 65,000-peso Mont Blanc pen as a ‘gift’ raise the question of ethical conduct, because of the expectation of reciprocity implicit in such an act. In fact, in other countries there are laws that criminalize politicians’ receiving of gifts – or failure to declare the like - to avoid exactly that. But how can one draw a line between the personal and professional? When students give gifts to their teachers; when employees give gifts to their employers; and when a private citizen gives pabaon to the assessor who just visited his own house to calculate property taxes, we see how institutions can be both functional and dysfunctional in our everyday lives.

Gifts, meanwhile, remain a powerful institution, a valuable currency and medium of social interactions in the Philippines.

Manila
September 2012

REFERENCES

Mauss, M. (1990). The Gift: The Form and Reason for Exchange in Archaic Societies, trans. WD Halls. New York and London: WW Norton.

Saturday, January 3, 2015

Health Financing: Who Pays for Health Care in the Philippines?

by Gideon Lasco, MD

Mang Torio, a farmer in Central Luzon, was in his middle 50s when he began to feel a lump on his throat. At first, he thought it was just a passing malady, but after a few months, the symptoms worsened. He decided to consult a doctor, and he was diagnosed with nasopharyngeal cancer - a rapidly spreading tumor that carries a poor prognosis: it can be fatal within several months or a few years. Even though there was little chance of recovery, his family put together what little funds they have to pay for the chemotherapy, surgery, and several weeks of hospitalization. Five months after the
diagnosis, Mang Torio was dead, his rice fields had been mortaged, and his five children were left without any funds to continue their education.

The sad story of Mang Torio is an everyday reality in many public hospitals in the Philippines. And it demonstrates how disease is not only a health problem, it is also a major financial burden. This is particularly true for diseases that require drastic measures and hundreds of thousands of pesos at short notice. Most people simply do not have enough funds to cover the expenses, yet life, priceless that it is, must be saved at all costs, and Filipinos will do everything to raise the required amount - from selling or mortaging farmlands to making emergency loans. The social and financial cost of these diseases, such as cancer, stroke, and heart attack, is so tremendous that they are called "catastrophic illnesses".

Addressing this vulnerability is one of the goals of universal health care. And one of the tangible solutions is a national health insurance program - this is what PhilHealth has been striving to be since its inception in 1995. In the Kalusugan Pangkalahatan program launched by the Aquino administration in 2010, "financial risk protection" is also listed as one of the three strategic thrusts towards Universal Health Care.

Who pays for health care in the Philippines? The answer to this question is always a combination of government, private sector, and individuals, but what underscores the importance of universal health care is that the proportion of what individuals shell out is too much. In health policy parlance, this is termed "out of pocket expenditure" (OOP). According to the World Health Organization, 20-30% OOP of health care is the healthy proportion. In the Philippines, the rate is a staggering 57%. This 57% does not only represent catastrophic illnesses, but also daily health expenditures. Patients purchase drugs, consult their doctors, and pay opportunity cost for their consultations and hospitalisations.

The rest of the health expenditure is spent by the government, through various agencies, including public hospitals that are subsidized. Politicians also dispense of government money, through their congressional allocations, to help their constituencies. Charity organizations, including the Philippine Charity Sweepstakes Office (PCSO) and the Philippine Amusement and Gaming Corporation (PAGCOR) actively engage with tertiary hospitals like the Philippine General Hospital; social workers usually facilitate how health care is subsidized, how much is subsidized, and who gets subsidized. These donor-individuals and agencies perpetuate the notion of health as a form of charity and as a tool of political and corporate patronage, and does not move towards a social consciousness of health as a shared responsibility of the people.

The move for governments to take an increasing role in health, and an increasing share in paying for health care, is justified whether one sees health as a means or an end. Those who see health as a means invoke the role of health in development and economic productivity. On the other hand, those who see health as a end in itself focus on “health as a right”. These perspectives are in agreement in seeing out-of-pocket expenditure as something that must be decreased if we are to achieve Universal Health Care.

On the other hand, it is not enough to ask how we finance the healthcare of individuals. The other side of health financing, which is probably more challenging, is how to get the funds in the first place, for government to be in the position to assume a greater share of health spending? There are two schools of thought in this matter, one advocating for a social health insurance scheme, in which voluntary contributions are given by its beneficiaries, usually according to their ability to pay (the rich pay more; the poorest of the poor pay nothing). The recently-enacted health care scheme in the United States, popularly known as “Obamacare”, is a move towards this direction, and through PhilHealth, this is where the Philippines lies as well. On the other hand, there are also those believe that this system should be rejected in favor a tax-financed system;  just get the necessary health costs from taxes. Countries that have adopted this scheme include the United Kingdom and Thailand. Although we are pursuing a socialized health insurance scheme, there are those that suggest that we move towards a tax-based system.

Within the current policy framework, however, how can we thus improve health financing? Let us discuss the solutions that are on the table.

The three dimensions of universal coverage 
The World Health Organization speaks of three dimension of universal coverage. These dimensions are also means by which out-of-pocket expenditure can be lowered. The three dimensions are: Who gets covered, What is covered, and how much is covered.

Expanding population coverage, particularly to populations without ready access to health care, would obviate the need for them to consume their own resources for health care. However, the amount of coverage needs to be sufficient for all the expenses involved. In countries such as Thailand, even the transportation expenses of patients are reimbursed, since they have identified access to health facilities as a major reason for not seeking medical consult. This is true for the Philippines as well, and we need to adopt innovative strategies to make people more comfortable with health care. Finally, coverage should extend to catastrophic illnesses. This has already been launched by PhilHealth in July 2012, with the unveiling of the “Z Benefits for Catastrophic Illnesses”. Drawing from the illustration I used at the beginning of this article, Mang Torio's diagnosis of nasopharyngeal cancer is not yet covered in the benefits package of PhilHealth. This means that even if he were a PhilHealth member today, his illness would still be a heavy financial burden.

Efficiency through regulation and rational health care
An efficient health care system means that the money spent on health translates to beneficial gains in individual and public health. When people spend so much money on drugs and supplements of little or no evidence of benefit, we can call it a form of inefficiency. The government can solve this problem by regulating these pharmaceutical and 'nutriceutical' products and approving only those with clear indications and proven efficacy and safety. The technicality that supplements that do not seek any 'therapeutic claims' is exempt from the stringent testing that drugs are subjected should be rejected on the grounds that therapeutic claims are implicit on any product that associates itself
with illness or wellness. The Food and Drug Administration is mandated to implement these regulations, but it needs political backing of the government if it is to succeed.

Equally important in achieving efficiency in health is the avoidance of unnecessary procedures and hospitalizations. Fortunately, there is an increasingly growing body called “evidence-based medicine” that subscribes to the primacy of rigorous scientific evidence in guiding clinical and hospital policies and practices. Procedures such as CT scans, MRI, and laboratory tests are validated according to their ability to diagnose. Also, concepts in clinical epidemiology, which looks at disease patterns and distribution, such as “number needed to treat” . The weight of these studies notwithstanding, one must acknowledge that there are also economic motivation to pursue excessive health care. Thus, these tendencies have to be kept in check by professional societies as a self-regulatory measures, and by the Department of Health. The PhilHealth, which is becoming the major payor of health care, is also in a position to push clinical practice towards rationality by scrutinizing how patients were managed, given the diagnosis and the patient's history and physical examination findings.

Moreover, regulation of hospitals should also take into consideration the economics of health care. For four CT scan machines in one small town is obviously too many; investors seeking to return their investments would resort to coaxing doctors that practice there to over-prescribe a CT scan, either directly or indirectly; this would lead to unnecessarily procedures and the toll will ultimately be paid by the patients themselves.

Reforming the pharmaceutical and healthcare industries 
Reforms on drug pricing also have to be made, as drugs comprise a major amount of health expenditure. If the cost of drugs in the Philippines were as low as that in neighboring Thailand, it would cut spending on drugs into half, slicing the out-of-pocket spending by several percentage points. But why are we not able to do this? The answer lies in weaknesses in the regulatory infrastructure, as well as a weak local pharmaceutical industry that fails to provide any competition to multinational companies. The trend towards generic drugs and the rise of generics-only drugstores might change this, but four years after the Affordable Medicines Act of 2008, little has changed in the cost of many essential drugs.

On the other hand, healthcare, too, has to be regulated. Again, PhilHealth can leverage its influence. Already, it is implementing case payments which fixes the amount of cash that a doctor (or a hospital) gets for specific procedures. This move forces health care providers to work within certain

Legislative and political action
Restoring a health-promoting environment requires legislation in many areas. In raising revenues, the “sin tax bill” will be a key component, but the political debates about this bill are still ongoing, and it is likely that the outcome of this bill will be less than that for which it has been intended. In expanding coverage to reproductive health, an RH bill must be pursued. In strengthening regulatory agencies such as the Food and Drug Administration, new laws and amendments need to be introduced, although at times, the current legal framework is sufficient; but what is lacking is political support in carrying out these laws.

Ultimately, the health reform is a political process, and public clamor for health care is the catalyst that will move our leaders to act on it. Equally important, thus, are activities that raise awareness on health, such the Secretary's Cup of the Department of Health and its partners – a series of debates, talks, and town hall meetings that aim to build a constituency around Universal Health Care. The media should also participate in giving health issues a fair share of the public discourse.

CONCLUSION
Health financing remains a pressing challenge in reforming the Philippine health sector. Today, a majority of health care is still paid for by patients and their families, and this leads to catastrophes that ultimately affect economic productivity, and reduce overall quality of life in the country.

The general measure of a well-financed health care system is by looking at how much individuals spend for health care, an index termed “out of pocket expenditure”. Consequently, the problems in health financing can be augmented by moves that will (1) decrease out-of-pocket spending and/or (2) increase government spending, which is in turn enabled by generating revenues.

Under these two major domains, we have identified the following solutions: Expanding coverage according to the three dimensions of universal health care; Implementing reforms in pharmaceutical and healthcare industries; Pursuing measures that will raise efficiency and rationality of health care; and finally, legislative and political action.

As we end this discussion, it is important to state the one truism in health policy that cannot be ignored: that development itself is an antidote to health care; in general, as a country develops, so does its health care. While difficult to prove, the point here is that there are complex factors affecting health care that goes beyond the purview of public health or health economics. Also termed as “social determinants of health”, these factors are an invitation for multi-sectoral, interdisciplinary collaborations.

Ultimately, the conclusion we can make is that health financing in the Philippines requires a comprehensive approach that supports regulatory and legislative reforms aimed at raising revenue and reducing inefficiency; a commitment to expand the 'three dimensions of universal coverage', and a mechanism to increasing the capacity of the government to pay for health care, through raising revenues, and a strengthened, comprehensive, and sustainable health insurance system.

Manila
October 16, 2012