Monday, September 21, 2020

[Speech] "Silence is not history": Reflections on historical distortion and disinformation

Speech delivered on the occasion of BALIK KA/SAYSAY/AN: An Online Conference on Historical Revisionism on September 21, 2020.

In “Bamboo Girl” (2016), a short story by the fictionist Ian Casocot, the thirty-something  protagonist explores his mother. lifelong insistence that she came from a crack of a bamboo - like the mythical characters in our folklore. Of course, the protagonist finds out a very different truth, but in the process, he also understands his mother’s reasons for holding on her story. 

“We who are able to tell our own stories own the narrative,” he realizes, adding: “Silence is not history.” 

Casocot’s story comes to mind when I think of history, in light of yet another anniversary of Martial Law. On one level, it points to fact that, as the mother said: “We make our choices in the stories of our lives that we tell”. Of all the moments of our high school days - some embarrassing, many boring - we choose to highlight the most exciting ones, and choose to tell them in ways that make them even more exciting - or relatable. And as the years go by, we add or subtract detail; edit characters in or out; and proofread the past using the present as our style manual. 

Indeed, everyone engages in acts of ‘personal historical revisionism’.

On another level, it reminds us that, like a palimpsest, our nation’s biography is subject to rewriting and erasure. Just as the dictator and his wife successful cast themselves in the mold of the original bamboo couple -  Malakas and Maganda; Silalak and Sikabay - today they have been cast as the regents of a golden age of culture, infrastructure, and wisdom. Indeed, attempts to lie about the past and the present are as old as history. 

Let me quickly give three other examples of disinformation in history. 

When Jose Rizal climbed Mt. Makiling in 1887, he was accused of planting the German flag on its peak as an agent of Bismarck: an early example of what was likely state-sanctioned fake news.

When a cholera plague hit Manila in 1820, panic and fear hit the local and they blamed  the foreigners. “There has been a very shocking massacre of from thirty to forty Europeans of different nations of Europe, and of about eight Chinese, at Manilla.” One missionary wrote. "The perpetrators of this cruel act were the native Manilla people. The pretext was a supposition that foreigners had introduced the disease called cholera morbus, which had prevailed extensively, and was very fatal.”

A third example is much more recent: When a group promised to distribute Marcos wealth to Filipino citizens in 2017, thousands flocked to UP Los Baños - some coming from as far as Marinduque - to claim their share - one million pesos each - of the promised wealth.

Critics being subjected to fake news. Pandemics being the subject of disinformation. Filipinos being promised payment in exchange for supporting for a dictator. What else is new?

Well, what has changed today is that the denialism has become more brazen, and the technologies more powerful to amplify its most pernicious effects. One does not need to watch ‘Social Dilemma’ to see how intense the political polarization has become, how entrenched the ‘fake news ecosystem’ has become - to a point that it is possible to sustain people’s honest-to-goodness conviction that the earth is flat, that vaccines cause autism, or that Marcos is a hero.

Times have indeed changed from the time that Rizal climbed Mt. Makiling, and hardly no one remembers the 1820 cholera plague, except for historians who helpfully remind us of their relevance. 

But the two levels articulated above - the personal and the political - are not unrelated. While most of us are quick to take the view of history as fixed and final, our personal histories reflect that they are dynamic - and such a view doubtless affect how many people view history-at-large. 

And so, a time of pandemic, and in an age where our epistemology is no longer respected, how do we overcome ‘historical revisionism’ - or more accurately, historical denialism? And how do we overcome the fatigue, the seemingly futility, in insisting that a faithful account of past matters?

In the first place, we must ask ourselves whether our history itself has been a form of disinformation. For decades, Filipinos have been educated with Europeans and Americans as reference point, taught that we were inferior, that prior to Magellan we had no history to speak of, and that whatever civilization we have reached is thanks to the contributions of waves upon waves of people of increasing sophistication - from Indonesians and Malays to Spanish and Americans. For decades, too, our history - at least the way it has been taught - has focused on a few people, a few regions. Is this also not a form of disinformation - or at least, a distortion? Is it not also damaging to nation building? Thankfully, the historians and social scientists of today know better and even the balangay has been revived. But the damage of “history as disinformation" remains. 

Secondly - and this will occupy much of my attention in this speech - we must invest facts with an affective quality. Can our history make people feel what it means to be an indio ruled by insulares and peninsiulares? Can we convey the anger of 1896, the fear of 1972, the euphoria of 1986, and the hope, however fleeting, that followed?

The fact that Jose Rizal choose to communicate his ideas in the form of novels speaks of his intuition that reason is not enough. It is not enough to indict the abuses of the Catholic Church at the time - one must construct the character of Padre Damaso. And it is not enough that Crisostomo Ibarra experienced injustice - he must have fallen in love. Rizal’s martyrdom in Luenta - just like Ninoy’s assassination in the airport that now bears his name - communicated what their ideas cannot - and at least for a moment, such events were compelling enough for people to take action.

Ironically, while Rizal recognized the value of affect, he himself has been treated by our textbook in a disaffected way. In the process of requiring Rizal for our students; of apotheosizing him in our historical canon - we have cut him off from an affective bond with young people. Only when I became a doctor and social scientist did I come to truly appreciate Rizal - his mountain climbing, his anthropology, his nation-building project. 

On the other hand, when we consider Fernando Poe Jr., and how his ‘death’ in his films evokes grief and anger among early cinema-goers, we see the power of this affective quality. His films communicated a truth that no political career could ever match: his relatable underdog-ness, and the goodness of his character.

Similarly, Rodrigo Duterte entered people's consciousness as a folk hero, which I believe continues to explain his appeal. Long before he ran for president, people have been hearing of his acts of kindness - whether imagined or real - from disguising himself as a taxi driver or traffic enforcer - to giving aid in times of disaster. Faced with a sense of historic injustice, people saw his own brand of injustice as justice. Duterte also understood the power of symbol - from the kulambo that communicated a simple life to the broken shoe that could dispel - more effectively than all the SALNs combined - the existence of hidden wealth. 

As for Ferdinand Marcos, he was also a master weaver of narrative, faking war metals and manufacturing the story of Yamashita’s gold, which is so effective than until now, it lives on, able to drive people from as far as Malabon and Marindique to the grounds of Los Baños. The gold may be fake, but people’s hopes on it were real.  

This brings me to the point I would like to emphasize: the role of creativity, the role of literature and arts. If empiricism and logic - if documents and testimonies, of amount of billions stolen, are insufficient, then we need to locate history within people’s affective realms for it to matter. 

In other words, we need to create a “cinematic universe” out of our history - one in which it is impossible to mistake Sauron for Gandalf, one in which people can relate to the characters, one which contributes to a sense of nationhood by reflecting and reinforcing our shared experiences. 

In fairness, and much respect, to our artists, directors, scriptwriters - they have tried. We have films like Respeto and Ang Panahon ng Halimaw documentaries like Aswang. And of course, music - like that of BLKD. We only have to remember the late Carlos Celdran to realize the value of performance and richness of our cultural history as a resource for such. 

But have we maximized this resource? If we had the clairvoyance in 1986 to see the events of 2016 onwards, would it have been changed how we treated Martial Law and its many unsung heroes in film and TV? Would it have have placed different words in Heneral Luna's mouth? Can we imagine Liza Soberano as Lorena Barros?

As J Neil Garcia rightly observed, even myths can “animate the character of our national reality”. For as long as Lam-ang remains relegated to textbooks, he will not reach the level of Black Panther in our imagination. Art can breathe life into history, while history itself can breathe truth into art. 

And so as we continue to grapple with an age of disinformation,  I would like to raise the affective possibilities that lie in our history. Historians rightfully warn that such projects carry the risk of distortion, but, whether we like or not, our history being distorted - the question is how do we respond. 

Of course, such projects run into the conundrum of popularization, of the need for “public engagement” - especially in our time when even TV networks are playing second fiddle to social media and its rising breed of influencers.

One things going on our side, however, precisely because criticism is natural for artists, scholars, journalists, and concerned citizens - many of us remain committed to historical record, and open to scientific evidence wherever it might lead. From 2016 onwards, a growing awareness of the existential threats faced by our democracy has led to a sense of community  not seen since the 1980s.

Another is the possibilities afforded by our age is the very platform we're using to make this event possible: the Internet. Yes, we have been on the receiving end of its dark side. But there may yet be emancipatory possibilities that we have not discovered. But the “influencers” of today, many of them young people, are reaching their generations in ways we never can, and some have used their influence to make known their politics. Even celebrities - untethered from their networks - are speaking out. Just as Rizal used the novel to communicate his ideas, we may yet see new media serve as platform for change - whether to get people to vote to stem the tide of disinformation.

To maximize these opportunities, the collaboration between scholars and artists has never been more critical. Unfortunately, our unnecessary divisions - institutional, disciplinal, regional, linguistic, and otherwise - have existed long before the arrival of a divider-in-chief who won by a minority of votes. 

This collaboration should not just multi-disciplinary but inter-generational. Our young people need mentoring. Our elders need coaching with the new technologies. We must reach out to people older and younger than us if we are to serve as generational chains. The idea of mentoring, alas, has faded in light of a commodified education system. But we can bring it back. Can. we challenge ourselves to have at least one intellectual sounding board representing every decade?

Finally, it has to be inclusive. Reducing Martial Law as a dualism between the Aquinos and Marcoses excludes people who do not identify with either. Reducing our country’s history to events that took place in Tagalog-speaking provinces excludes people for whom Tagalog is second language. Reducing our pantheon of heroes to mostly-male illustrates and mostly-elite presidents excludes women, indigenous peoples, and many others. Local histories can bring about a sense of dignity and responsibility - but we need to support state universities, our educators, and the patronage politics that afflicts our educational system. 

Of course, we must affirm the dualism between indelible truth and outright lie. Even in this post truth age, fact checking has forced presidents like Donald Trump and Rodrigo Duterte to retreat in their unfounded claims - from fake cures to false hopes. Even in this post truth age when money can help buy elections through social media - we have seen a woman rise from relative obscurity to defeat the dictator's son. Contemporary rebuttals will also speak louder than future corrections - so thank to our journalists for the critical reporting. 

But we also need an openness to various narratives - like the mother who insists that she came from bamboo. It is not enough to have a villain. We need heroes too - not just one, but many. If we are to build a cinematic universe out of our history, we have to bring out the diversity that is already here to begin with.

Let us bear in mind that, if, as in Casocot's story, “silence is not history”, then we must not tire of our raising our voices. We must not get bored with our own stories. Because our tyrants rely on our amnesia to escape accountability, memory itself is a form of resistance. Yet we must find new ways of retelling. If Darna can be recast and remade, surely we can remind people of the real-life heroes whose only superpower was courage. 

I will end by offering a sigh of relief - or perhaps even a modest declaration of victory. We have made it this far. In the middle of a pandemic, in the autumn of the dictatorship, we are talking about historical record, striving to find a common ground that is big enough to build a country. The very fact that we are having this conversation is hope enough for us - at least enough for us to persist in this project of affirming our right to history - one that is true, one that is inclusive, one that can change people’s minds and just as importantly, touch their hearts.

Gideon Lasco
September 21, 2020

Tuesday, September 15, 2020

[Speech] Realizing social medicine, revolutionizing health for all Filipinos

Keynote speech delivered at the National Medical Students' Conference - August 8, 2020.

My beloved colleagues, dear friends, students of medicine, fellow learners and fellow Filipinos, good morning to all of you. Let me begin by acknowledging that we are in the middle of a crisis - one that is biomedical as much as it is environmental, social, economic, and political. By all measures, and despite the costly sacrifices we have made in the past several months, the virus remains out of control, and our health care system has reached its breaking point. 

I also acknowledge that on top of this unprecedented emergency, I know that many of you are facing academic, financial, and mental struggles as a result of the pandemic. Some may not even know how the school year will be carried out; how your training can continue. Truly, many emotions cloud our minds today - from uncertainty and sadness to boredom and anger. 

But this is all the more reason why I would like commend the organizers for persevering in putting together this conference. I don’t know how many Zoom meetings you attended, how many virtual work sessions you went through, but I congratulate you for mustering the strength to push through with this important activity. I also thank all the participants for joining us today, whether you are in your homes with your family, in your apartments by yourself, or in the callrooms of our hospitals as among our frontliners. I salute all of you, and share with you the determination to continue our work and advocacy. 

 In fact, the pandemic has made the theme of this year’s conference more relevant than ever. 

 There is no tougher exam than the pandemic -and there is no samplex for it. Incidentally, exactly ten years ago this very day, also on a Saturday, I was in UERM taking the board exam and there was a question about effect of sulfur inhalation in the lungs, leaving most of us completely clueless. Luckily, I actually experienced being surrounded by sulfur fumes while climbing a volcano in Indonesia, and from the sole basis of that experience, I ended up with the right answer: wheezing and shortness of breath. 

 Unlike the most difficult exam, however, where there is ACTUALLY a correct answer - at least most of the time - we do not even know if our answers for the pandemic are correct. Should face shields be recommended - are they effective, and are they cost-effective? Is 1 meter physical distancing enough? Are rapid antibody tests a good use of our dwindling resources? Even our best doctors don’t really know for sure - and you may have seen your own professors engage in passionate debates in social media to litigate some contentious points. The fact that the DOH, CDC, and WHO all changed their recommendations about face masks means that they are likewise facing this lack or certitude. Science, as we have seen in the past months, is neither definite nor independent from social and political influence. We are learning to be critical the hard way - but even all our criticality put together cannot constitute any certainty as what lies ahead of us. 

 Despite the fact that we do know enough, we soldier on, in the same way that our predecessors in 1918 faced an unknown illness that would come to called the Spanish flu pandemic, a pandemic that claimed the life of my great-grandfather, Silvestre Diaz, in San Pablo Laguna alongside 80,000 other Filipinos, and millions around the world. Lest we forget, Dr. Jose Rizal volunteered his medical services for Cuba before his martyrdom in Luneta, even if it meant being on the side of the Empire has had criticized. Lest we forget, interns and residents kept the Philippine General Hospital running even in the bloodiest moments of World War II - with 27-year Honorato Quisumbing losing his life in the process. 

 Thankfully, not all pandemic-related questions are unanswerable. Not all pandemic-related issues are medically contentious. And not all pandemic-related facts are equivocal. We know from the experiences of other countries that the more testing and contact tracing we do, the better we can control the pandemic. 

We know from our experiences with HIV and TB, that fear and shame will only make it harder to test and treat people, while adding social and emotional pain to their illness. 

We know from the failures of the so-called drug war, and from the experiences of those living and working in communities both urban and rural, that a public health crisis requires a public health - not a military, not a police, and not a punitive - response. 

But adding to our frustration is the fact that even if the answers are very clear, it is the incorrect answer that informs many of our policies and programs. People who need testing have been denied testing, even as people who simply desire it are granted their wish with much faster results. People who test positive are threatened with shame campaigns and treated like criminals, even as law enforcers who flout the law are given a free pass. Low income households and communities - already more susceptible to disease by virtue of poor nutrition, and more vulnerable to infection by virtue of their work and living arrangements - are further encumbered by misguided policies that hurt more than they heal. 

 All of the above are making us realize the urgency of the topic at hand, which is social medicine, and the ‘revolution’ that a move towards it entails. 

 So what is social medicine? Just like ECQ, GCG, and mass testing, we need to define our terms carefully. Personally, I consider social medicine not as a separate field or branch of medicine but as a framework that broadens clinical concepts such as “diagnosis” and “treatment” to include social, economic, and political pathologies. It views people not just as patients in need of cure, but as people with knowledge and agency with whom doctors must work to attain the well-being not just of individuals but of communities and nations. 

I would like to break down this framework of social medicine into three functions - bridging medicine and society, bringing medicine to society, and bringing out the “social” in medicine. 

Bridging medicine and society

The first is bridging medicine and society, that is bridging people’s experiences and knowledge of health and illness with our biomedical knowledge, facilitating understanding of both sides.

 For a long time, clinical medicine rested in the assumption because diseases were an objective reality, we didn’t really need the patient’s words - except in aid of diagnosis, and even them, symptoms were seen as inferior to signs. The laboratory tests told a truth that no clinical history can match. If one can see a Ghon focus on chest X-ray, and have a positive sputum smear, it didn’t matter where the patient came from. As long as they take medicine for 6 months, you’ve done a great job. 

 Of course, even then, intuitively, clinicians knew that they had to win rapport - a charismatic doctor is more likely to convince a patient to take the medicine for 6 months. A family-oriented doctor is more likely to get the patient to take the medicine for 6 months by motivating his wife or husband. And a community-oriented doctor is more likely to get the patient to take the medicine by understanding the barriers to care - perhaps the clinic is simply too far. 

 But this was not emphasized in medical school, which drew on an objective reality as its epistemological paradigm, confining itself - at best - to the interaction between the doctor and the patient in aid of diagnosis. 

What goes on outside the clinic is none of the doctors’ concern - as long as the patient complies with his orders. 

What the patient says is none of the doctors’ concern if it does not align with his own clinical understanding. 

 What’s happening to the environment - from the movement of animals to the decimation of our forests- is also none of doctors’ concern unless there is a clear association with a disease. 

As a result, despite the breakthrough discovery of antibiotics and vaccines that have saved millions if not billions of lives and made many people in the 1960s optimistic that medicine can actually end disease and suffering, medicine has not been very effective in reaching its goals. 

 Let me give you one example. In a not-very-well-thought-of measure, doctors in the 1980s tried to euphemise tuberculosis by calling it “mahina ang baga” - instead of educating people about stigma and aggressively dealing with TB. What happened to “mahina ng baga?” 

 Well, to maintain the fiction of “mahina sa baga”, doctors could not tell patients that they needed medicine, because, based they were not supposed to be sick. So how did they call Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol? 

Vitamins sa baga. 

 And what did people do with vitamins? They used it as vitamins - only when they have symptoms, only when there’s a health threat, like today’s pandemic. Needless to say, this whole “mahina sa baga” discourse has been undermined the entire TB program, and today we continue to struggle with a disease that is still on track to kill more Filipinos this year than COVID-19. 

A social medicine framework tries to bridge the doctors’ knowledge and experience, as well as those of the patient, through the recognition, first of all, that local knowledge matters.

 The case of “mahina ang baga” points to the fact that biomedical knowledge often gets lost in translation.

The case of tu-ob is also illustrative. When Governor Gwen Garcia of Cebu recommended tu-ob as treatment for COVID-19, it invited ridicule and rebuke, to some extent justifiable, from health professionals. But tu-ob makes sense from the perspective of people’s ‘explanatory models’ or ‘folk physiologies’ or how they understand the workings of the body. To start with, it is not accidental that the word baga means both ‘lungs’ and ‘embers’ in local languages including Tagalog, as in sunog-baga, nagbabagang apoy, nagbababagang balita. Lungs are seen as embers of the body and as a “hot” and “dry” organ. Thus, anything that that’s cold and wet is seen as pathogenic, which is why people are anxious if they are ‘nalamigan’ or ‘naambunan’. 

Thus, masseurs will insist on removing the ‘lamig’ in your back as they might enter the lungs, which, when melted, is seen as explanation for phlegm or plema. 

Conversely, anything that’s warm is seen as therapeutic for the lungs. For a long time, smoking cigarettes is seen as therapeutic, and this is actually an idea shared around the world - even the young asthmatic Che Guevara received some a special kind of cigarette as an asthma treatment. Hence, it’s very easy to convince people to nebulize - you don’t have to convince people that nebulization works because it goes along people’s folk physiologies. 

Hence, people are sympathetic to therapies like ‘tu-ob’, also known as ‘saab’ or ‘luop’. Such realization, of course, will not change the fact that ‘tu-ob’ does not cure COVID-19. But if we understand where people are coming from, they we will be more respectful and effective in our response. In my own research, I have explored notions of blood in relation to hypertension and found that ‘high blood’ is seen as a function of blood viscosity - malapot or malabnaw. One implication is that because anemia is seen as malabnaw while high blood is seen as caused by malapot na dugo, many patients think you can’t have both anemia and hypertension at the same time, which of course is not true. 

So yes, local knowledge matters, and we also see it in disease outbreaks such as SARS to COVID-19. Local notions of ‘hawa’ and ‘resistensya’, as well as concepts of ‘loob’ and ‘labas’, affect the decision on what vitamins and food to consume, whether to use face masks, and when to do physical distancing. 

Aside from local knowledge, words also matter. Our choice of words matters if we are bridge the gap between doctors and patients - and between public health and the public. Also, understanding people’s choice of words matters if we to connect to them. Words give form and shape to our realities, which is why many words cannot neither be translated nor fully understood apart from the culture in which it is used. For example, words like “kilig” and “sayang”. 

 In medicine, we tend to quickly translate words without trying to learn from them. Sometimes, patients are too embarrassed to use their own terms. However, words have value in themselves: To respect patients’ words is to dignify their narratives; to take those words seriously is to be a better doctor 

One peculiarity of our local languages is that words that have similar meanings tend to share the same root. So when people say “hingal” and “hingalo” people usually mean something that’s pulmonary, whereas hapo is cardiac. We need more studies to explore symptoms using patients’ own words. 

Finally, symbols matter. Everyone knows that the stethoscope is a symbol of medicine, but not everyone taps into the power of this symbolism. If we view the stethoscope only as a tool for diagnosis then we will only auscultate when needed. But if we view stethoscope as a symbol of listening to one’s patient and reassuring the patient that you listened to their body, then you will auscultate. 

Bear in mind that before the invention of the stethoscope, doctors actually put their ears on patient’s chests to listen to their breath sounds and heart sounds. Do we also listen to how people understand their conditions? At the heart of social medicine is recognizing that just because something does not exist in our textbooks doesn’t mean that they do not exist in the lived realities of our patients. As Che Guevara once said: “We should go with an inquiring mind and a humble spirit to learn at that great source of wisdom that is the people.” 

Bringing medicine to society 

I just talked about how social medicine bridges medicine and society by seeking an understanding of both, and explaining one to the another. 

 Secondly, social medicine also strives to bring medicine to society - and make health - not just health insurance, not just free medicines - available to everyone. In other words, social medicine recognizes that socialized medicine is not enough. 

If what I just said sounds lofty and high sounding, that only goes to show how jaded we have become. And I understand. Who wouldn’t, in light of the obscene corruption in PhilHealth? Just like some of you, I have been in an ER triage where your residents tell you that you have to turn a patient away, despite the desperation in their faces. Today, we see so many people struggling to find a ward or a bed willing to accept them. Our health care has been “covidized” - we want to deal with a pandemic but many other illnesses are being sacrificed. As applied to COVID-19, a social medicine framework uses people’s actual health needs - not political imperatives - as a starting point for policymaking.

Social medicine also recognizes that if we are to bring medicine to the people, then we cannot rely on ourselves - our mistake is sometimes to think that we alone have this burden - and that we alone have the knowledge and expertise. Medicine is too important to be left to the politicians, but it also too important to be left to doctors. 

We need to involve families, community members, including the barangay health workers. In Bangladesh, I have seen how community health workers, sufficiently empowered, can actually make a huge difference in TB programs. Among others, they incentivized their “shastu shebikas” - for every successful DOTS treatment, they will get a reward. And it worked, because they were recognizing the social capital of community members. 

 In Cuba, meanwhile, I saw how a strong primary care - with focus on immunization and prevention - can make a country have better health outcomes than the US - even when their hospitals have fallen into corruption and disrepair. One other strength of Cuba is that they have their own pharmaceutical industry - they even make their own vaccines - giving them resilience in facing health crises. A social medicine approach will also question why we are not able to do this. 

Towards the end of bringing medicine to society, we should involve health psychologists and communicators to help understand human behavior and what messages are most effective. We should involve social scientists to help us explore the barriers to care. Oftentimes, we think that the problem is money alone, but the social sciences can tell us otherwise. For instance, at the height of the dengue vaccine scandal, we have parents saying “I would rather die of dengue than the dengue vaccine.” Where are these sentiments coming from? How can we understand anti-vaxxers, conspiracy theorists around COVID-19? When we say “culture” in anthropology, we do not just mean indigenous knowledge. It encompasses the rapidly-evolving practices, from the use - or non-use - of face masks to the appeal of steroid injections and alternative cancer treatments. 

We can also involve historians to tell us of the lessons of our past. At the height of ECQ, one of the personal projects I embarked on is to write a social history of SARS in the Philippines, and what I have seen is that many of what we’re seeing today have actually been foreshadowed before. What have learned from previous outbreaks? How can we make sure that the lessons of COVID-19 are available for future reference? 

Social medicine, in other words, calls for tapping into our creativity, expertise, and people-centered collaboration to achieve better health. Not just health outcomes that are tangible, but intangibles like respecting cultural knowledge and upholding the dignity of people’s lives and livelihoods. 

Bringing out the “social” in medicine 

Social medicine bridges medicine and society by seeking an understanding of both, and explaining one to the another. It brings medicine to society by interrogating biomedical and neoliberal notions of ‘health care’ or ‘socialized medicine’ and identifying barriers to culturally-sensitive ‘heath for all’. 

Thirdly and lastly, social medicine brings out the “social” in medicine by identifying the social and political pathologies that cause disease and suffering. Social medicine argues that illnesses are socially determined, and that heath cannot be disentailed from environment, economics, and history, even colonialism. 

In one powerful example of a concept he called “structural violence”, the medical anthropologist Paul Farmer narrated HIV/AIDS in Haiti and argued - by a retelling of its history, that we cannot talk about HIV in Haiti without talking about its history of colonialism and slavery; of an uneven globalization that made the country perpetually sunk in debt, at the mercy of its debtors like the US, and chronically poor, rendering its people vulnerable to sex work and sex tourism. Despite a history that implicates colonialism, people ended up blaming and stigmatizing the people of Haiti for HIV in what farmer calls “geography of blame”. 

Another example is dengue in the Philippines. What causes dengue? A virus. What carries the virus? A mosquito. But if we dig deeper, we can start asking questions like, where did the mosquitos come from? Who gets affected the most? Aedes aegypti thrives in stagnant water which rarely occurs in communities with forests intact. In fact, Aedes aegypti became widespread in the Philippines due to the clearing of land for sugar plantations and for cities, with the increased temperature due to deforestation also contributing to increased mosquito bioactivity. So we cannot talk about dengue without talking about deforestation brought about by colonialism, of access to flowing water, of stagnant economies, and of land use as vector of disease. 

Many of you are familiar with ‘Kuwento ni Rosario’, the classic of community medicine, that every medical student - at least in PGH - goes through. When I was in South Africa, I had the opportunity to meet community health organizers including David Saunders, a pioneer of the global primary care movement, and one activity they organized had a story that was very very similar to ‘Kuwento ni Rosario’, which got me wondering if there’s any connection. As in turned out, yes, there was. ‘Kuwento ni Rosario’ was written by Gerry Andamo and community health organizers led by Dr. Delen Dela Paz in early 1980s, after a visit by David Werner, who worked with David Saunders and inspired case studies based on chain of causes or cadenas de causas. 

David Werner was in turn inspired by his community experiences in Mexico, as well as the writings of Paulo Freire, the Brazilian philosopher who called for empowering communities to understand the roots of their problems. 

What can we learn from the ‘kuwento ng kuwento ni Rosario’? 

First, it is harder to look away from a face than from a disease. Every day we are given numbers. Yesterday, DOH reported 3226 new cases and 46 new deaths. But behind numbers real people. If we are to bring social in medicine, we need to tell stories like Rosario’s because while numbers dehumanize, narratives humanize. 

Second, we really cannot tell which of our little acts will make a difference. The people behind Kwento ni Rosario didn’t realize how much an impact the story would have for generations. Don’t underestimate your own stories, writings, community involvement, advocacy work. Maybe a public health lecture, an article you wrote will inspire someone, which will in turn inspire another. 

Finally, the fact that Rosario remains resonant today as it was in the 1980s means that much more needs to be done today - we have not really addressed the root causes, and the same factors responsible for the death of Rosario continue to claim lives today. Social medicine - through concepts like structural violence and social determinants of health - gives us a vocabulary with which to demand reform - and call attention to the chain of causes that underpin people’s health. 

Why 'revolutionary medicine'? 

All of the above might sound good. But why has it not been done? Why do we need a revolution for something that’s seems clear and obvious?  

Social medicine is by nature revolutionary because it goes against the status quo.

First of all, the demands of social medicine are politically inconvenient. It is easier to just dole out ayuda, instead of building health care capacity. The first approach creates ‘utang na loob’ for politicians, the second approach opens peoples eyes to the fact that politicians are part of the problem. It is also safer for doctors to just stick with clinical facts - if they start looking at the problems of government, what Rizal calls social cancer, they will go after you. Pushing for an RH Law or pharmaceutical reforms will earn you enemies - even the “No approved therapeutic claims” at the end of food supplements today was secured at the cost of lawsuits.

Secondly, it is financially inconvenient for many people involved. Regulating the cost of medicines and  medical procedures may lead to lost income, and if there are more doctors, the price of healthcare will go down - alongside doctors’ income. Moreover, strengthening the public health system may also mean lost revenue for the private sector. Are we willing to do this?

Thirdly, it is epistemologically inconvenient. As doctors, we are still trained to view randomized control trials and other 'robust evidence' as the gold standard. Given our training, it is inconvenient for us to take patients seriously. It will require a culture change within the practice and teaching of medicine for attitudes to change. 

Finally, it is symbolically inconvenient. Social medicine entails doctors letting go of our status at the top of the pyramid. Let’s face it, being a doctor is prestigious. We get all the credit for treating patients, and we are the face of healthcare - despite attempts to vilify us. However, medicine has its own authoritarian tendencies, which explains why many doctors warm up to the idea of a dictatorship. Likewise, public health is utilitarian by nature, which similarly explains why many doctors think the ends justifies the means: If building a nation requires cutting the jobs of 11,000 employees, so be it. If having a drug-free Philippines entails the collateral damage of tens of thousands of victims, so be it.

To a certain extent, this is understandable: if you are a surgeon in the OR, you have to make decisions by yourself. You cannot consult your colleagues - let alone the interns and residents by your side. There is no time. Too many decision-makers will only delay healthcare. And if you are an orthopedic surgeon, you know that sometimes you need to cut a limb to save a life. The ends justifies the means. 

Even so, we know that, writ large, this analogy is dangerous: a cell, a tissue, an organ, or even a limb cannot be compared to human life, each one of which has intrinsic value. Moreover, while in certain situations we need someone to make decisions STAT, we still need to make sure that that person is actually competent, and knows what he is doing, and that he is not abusing his authority. 

The surgeon in the OR analogy is also limited because among the consultant, resident, intern, and clerk - it is truly the consultant who has the most experience. But when dealing with people’s health, we do not have a monopoly of knowledge. We do not know what goes on when patients leave the clinic. We do not know the communities’ resources and struggles. And we do not know how to communicate effectively as well as those who actually devoted the same amount of time we spent in medical school studying communications. 

All of these barriers - from political to symbolic - tell us that we cannot just allow the status quo to take its course, no more than we should resign ourselves to waiting for the pandemic to die out - or for a vaccine to be developed. If we are to realize social medicine in the country, we need nothing short of a revolution. 

Conclusion: Realizing social medicine

We need a critical mass of people using a social medicine framework in guiding their ethics, politics, and clinical practice. To go back to Paulo Freire, we need to work towards “critical consciousness” that enables people to understand why we do what we do, why we are where we are, how we are to overcome the things - and people - that are holding us back. 

You do not have to be a full time medical historian or anthropologist to practice social medicine. You can practice social medicine in your clinic when, the next time a patient comes in and tells you that she has “usog”, or “panuhot”, or “na-barang”, your attitude is curiosity and empathy. 

You can practice social medicine in your hospital by insisting that patients be at the center of care. While doing fieldwork in a people-centred hospital in Singapore, for instance, I saw how patients parking is closer to the hospital than those of non-emergency staff, and the waiting rooms have TV screens and tables with power plugs so patients can work and relax while waiting. That’s not just good business - it is dignifying patients’ time, respecting their worth. 

You can practice social medicine in public health by insisting that we use not just one lens in looking at one problem - but multiple lenses, from people's lived experiences to macro-analysis that implicates the pathologies of power that ultimately affect people’s lives, and indicts the people responsible for our health problems. What good is taking health financing course, and writing a masters thesis on how to improve Philhealth, when its executives will just steal our funds? Will you not protest? But at the same time, what good is an outpatient benefit package if people cannot even afford transportation, if clinic hours overlap with working hours? Will you not want to understand how people actually live their lives? 

Towards this end, we can also demand curricular changes that give medical students more opportunities to learn about social medicine, immerse themselves in society, and equip themselves with skills that you need. Isn’t health communications a necessary subject, especially in this age of fake news and social media? Shouldn’t doctors be equipped with an awareness of governance and politics of health, given that we all have to deal with decision-makers and politicians? Should we be equipped with a stronger medical humanities background to help us make sense of illness, death, and suffering? 

Can we not place cultural competency at the same level as the ability to conduct a physical exam? And can we not insist that just as important as interpreting an ECG is interpreting what people mean when they say hika, hikahos, kalos, hingal, hingalo, sinat, lagnat, binat

Beyond curricular changes and academic matters, we can make our voices be heard - there are many platforms. (On this note, I would like to commend those of you who are bravely making your voices be heard in social media. You are not alone, and you should never feel alone whether in your medicine or in your politics.) 

While we need to recognize our privilege, we should also not hesitate to use our privilege to advance our advocacies and causes. As doctors, people listen to us - even if leaders don’t always act on what we say. We have made gains in the past - however inadequate and imperfect - from the Milk Code and Generics Law to RH law, HIV/AIDS law, and to certain extent, even the UHC Law. The fact that Duterte himself grudgingly responded to the medical societies’ open letter means that collectively, we have a voice that we can use. 

As for the individual level, we can also realize social medicine for ourselves by broadening our horizons. I have already mentioned the need to look at patients as resource persons, as teachers - and we can do that with every clinical encounter, but with every adventure - even when you climb a mountain you can learn from communities you meet along the way. Simple acts and gestures can also be revolutionary in their own way. One of the things I learned in Cuba about the life of Che Guevara was that whenever he visited factories, he did not inspect them. He took part in the work. When he visited construction sites, he took part in the mixing of cement. What he was doing, with his actions, is the dignification of manual labor. 

I must confess that when I was a clerk I thought that it was beneath us to be told to do “scut work”. Only now do I realize the lessons I could have learned by welcoming such tasks. By pushing a stretcher bed, we are being taught to put ourselves in the feet of our patients and their bantays. By pushing IV meds, and doing all kinds of hospital procedures, we are being taught to put ourselves in the feet of colleagues who we lead and will work with. Ultimately, the only thing that is beneath is is the abandonment of our duty to do no harm; to be role models of health; and to value every human life - whether she is a person who uses drugs, a person with COVID-19, or a person whose beliefs are opposite yours. 

I also mentioned the importance of books in the curriculum, but we can read books on our own, and we can also write books, stories, essays ourselves. Some of our medical colleagues have penned and edited their books - Drs. Joti Tabula and Ronnie Batiuclon and I hope we can have many more such accounts in the future. As I wrote in Dr. Tabula’s edited volume, I wrote: 
“When a future generation looks back…what stories can we provide? What evidence can we offer that we, in the midst of our hospital lives, contemplated about death, cared deeply for our patients, worried about our seniors, and even managed to fall in love?” 

Writing does not just humanize our patients - it also humanizes us in their eyes. As I wrote in the foreword to Dr. Baticulon’s book: 
“In an age where doctors are both idealized and vilified, we need accounts that place them in their rightful place somewhere in between: frail in their nobility, and noble in their frailty.” 
Travel and learn not just from the places but from the people from different perspectives and persuasions. In the Galapagos Islands last December, I saw a fragile ecosystem affected by humans, and realized, more than ever, that environment and health cannot be disentangled, we have develop a more-than-human consciousness if we are to solve the problems of this troubled century. 

In the Rohingya camps, meanwhile, I met refugees with a painful past, a difficult present, and uncertain future. Just as it is difficult to forget Rosario, I cannot look away from the Rohingyas and am currently working with colleagues in Southeast Asia to raise awareness of migrant health issues in the region. 


Finally, in Ethiopia this January, just before the world closed down, I trekked in mountain communities and experienced the shared humanity that should be at the heart of our medical practice: further realizing  that every culture deserves understanding and respect; that every human life matters; and that there far more than unites than divides us. When children approached me, I actually thought that they were asking for food or money. “They just want to hold your hand,” my guide told me. “They are welcome you to your village.” 

Personally, I have found social medicine to be an exciting framework for my work, advocacy, and way of life, allowing me to channel my interests and passions to something meaningful and adventurous. For those of you who are unsure of what kind of medical path to take, please consider joining public health, and I would love to see some of you take up medical anthropology.

But like I said, social medicine is a framework that can be practiced by everyone, clinicians and non-clinicians, doctors and non-doctors alike.  

It will not be easy. There are parental and social expectations, difficulties that will make you think twice - maybe even twice a day - about the very idea of continuing medical school. Some advocacies require perseverance, and although writing sounds easier than going on a 24-hour duty, ask anyone who went through a dissertation and that person would argue otherwise. By being political in my writing, I have found myself in the crossfire. But as Dr. Jose Rizal once told his students in Dapitan, “Knowledge without courage is useless”. 

And so I invite you to discover and embrace a social medicine framework, one that would enhance your career, enrich your life, and allow us to overcome this pandemic. Together, let us bridge medicine and society, bring medicine to society, and bring out the “social” in medicine - towards revolutionizing health care in the country - and bringing, at all long last, health for all Filipinos.

Gideon Lasco
August 8, 2020

Friday, July 31, 2020

[Webinar] Face Masks: From Medicine to Culture, from Culture to Medicine


On July 31, I joined Dr. Michael Tan, professor, academician, and medical anthropologist, in giving a webinar entitled "Face Masks: From Medicine to Culture, from Culture to Medicine" organized by the Museo ng Kaalamang Katutubo (MUSKKAT). 

My lecture reflected on the meanings and efficacies of face masks, arguing that they are actually a familiar response to crises, and that they have come to signify conformity and 'good citizenship' even as also reflects people's individuality and personal preferences as part of an emergent bodily culture.

Some of the themes I presented are summarized in my Inquirer column the previous day.


Wednesday, July 1, 2020

[Webinar] ISSDP-UNODC - A scientific look at the 2020 World Drug Report



As a drug policy scholar and member of the International Society for the Study of Drug Policy (ISSDP), I participated in a webinar jointly organized by the ISSDP and the UN Office on Drugs and Crime (UNODC) on the occasion of the release of the 2020 World Drug Report, on July 2, 2020.

The webinar featured an overview of the World Drug Report by by Angela Me (Chief Research and Trend Analysis Branch, UNODC), followed by reactions from Suzanne Nielsen of Monash University, Alexander Soderholm of the London School of Economics and Political Science, and myself, with Alex Stevens (University of Kent) and Kaitlin Hughes (Flinders University) serving as moderators. 

In the webinar, I welcomed the attention to the socio-economic linkages of drug use, but argued that beyond looking at the impacts of drug use disorders on people's socio-economic lives, we should also look at how people's socio-economic contexts shape their use of drugs - both problematic and non-problematic.