[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.

[Short Course] An Introduction to Medical Anthropology - University of Sao Paulo

As visiting faculty at the University of Sao Paulo, I gave a short course entitled "An Introduction to Medical Anthropology" from December 4-9, 2019, in which I offered a broader view of health, focusing on the ways people make sense of health, illness, and bodily experiences - and discussing some contemporary debates within the sub-discipline with particularly relevance to the Global South.

The course covered four modules - " Situating culture in health, situating health in culture: Basic concepts in medical anthropology";  "The human life cycle: An anthropological perspective"; "The normal and the pathological"; and "The ‘lived body’: Exploring everyday technologies of the self".

In the first module, the class discussed the emergence of medical anthropology as an important subfield as well as foundational concepts like medical pluralism, the three sectors of healthcare, and explanatory models of disease. In the second module, we revisited the classic anthropological concept of ‘rites of passage’ to reflect on the different stages of the human life cycle.

Meanwhile, the third module discussed how medical knowledge and practice have structured modern notions of normality, deviance, identity, and community.

Finally, the fourth module reflected on ‘body projects’ in late modernity - from plastic surgery in Korea to skin whitening in the Philippines - and how these practices are situated in both global and local contexts.

[Talk] Health Leadership Summit - Medical Anthropology and Universal Health Care

On December 3, 2018, the Ateneo Professional Schools (APS) and Ayala Healthcare Holdings, Inc. (AC Health) organized a conference on Universal Healthcare (UHC), entitled Health Leadership Summit 2018: Universal Healthcare at the Ateneo Professional Schools Auditorium, Rockwell Center, Rockwell Drive, Makati City.

As one of the speakers, I gave a talk on "how medical anthropology can contribute towards health for all Filipinos". I gave three roles for anthropology and for the social sciences in general - namely, (1)  identifying gaps in the so-called three dimensions of coverage (2) informing the kind of healthcare in UHC; and (3) evaluating and critiquing ‘UHC’ and document its ‘lived effects’.

As the country moves towards health reforms, it is of vital importance that social scientists engage with the medical communities to make sure that the voices of patients and laypersons are heard and listened to - as to what kind of 'health' we're really talking about when we speak of UHC. 

[Talk] Folk Pulmunology

MANILA - As one of the keynote speakers at the 37th Annual Chest Convention of the Philippine College of Chest Physicians (PCCP), I talked about 'folk pulmonology', or patients' perspectives when it comes to their lung problems, in a 30-minute presentation on March 14, 2018.

Drawing from the work of Prof. Michael Tan and Prof. Anita Hardon, I introduced the talks with concepts like 'hiyang' and the idea that cough is a particularly "socially-disruptive" disease because it is both 'visual and auditory'. I stressed the value of language, referencing dying terms like dalahik and dahak that could enhance the specificity of history taking and help build rapport between doctors and patients. I also mentioned explanatory models such as the 'hot-cold syndrome': the lungs is viewed as a 'hot organ' and can therefore be affected by the cold.

I proceeded by presenting some insights, including the explanatory role of medicine: patients consult doctors not just to get well, but to find out what's happening in their bodies. I then concluded with a question: "What possibilities lie when we think of pulmonology not just as a profession that cures lung diseases, but one that allows patients to breathe better?"

Many thanks to Dr. Eric Moral and all the members of PCCP for giving me a chance to share my insights! This topic is something that only clinicians and anthropologists can do working together and I hope doctors will pursue the many research possibilities  - towards "culture-guided medicine" in the Philippines. 

[Second Opinion] When plastic surgery goes wrong

by Gideon Lasco
Philippine Daily Inquirer

On March 26, Shiryl Saturnino, 29, described as a “businesswoman engaged in the selling of beauty products,” died after undergoing three surgical procedures: breast augmentation, liposuction, and buttocks enhancement. The Metro Manila clinic where the operation was done has since been ordered shut, and the case is now under investigation.

Previous “cosmetic procedures gone wrong” have gripped the public in the past. In 2008, Mary Jane Arciaga-Pereira, 29, a vacationing overseas Filipino worker, died while undergoing liposuction in Quezon City; in that same year, Louem Martinez, 34, filed a P26-million suit against the Makati clinic where he had a “penis enlargement operation,” claiming that his organ had been deformed by the procedure
.
More recently, the face of Ellowe Alviso, 24, was reported to have been disfigured as a result of a solution injected into his nose and chin, which turned out to be “wax, petroleum jelly and sealant.” From a local model with big dreams, Alviso had turned into a balut vendor by the time the TV crews got to him.

These cases have particular valence in a country where many are obsessed with not just beauty pageants but also the pageantry of everyday life. And the people’s reactions to them say a lot about our shared values, expectations, and ideals of health and beauty.

In Shiryl’s case, many described her as a beautiful woman who “should have been contented with what God gave her.” As for Ellowe, many lamented his naivete, wondering why he believed that a P500-procedure could be real, safe and effective.

But some have also pushed back against this “victim blaming,” calling for sympathy for people who have suffered the consequences of their actions, and whose beauty aspirations are actually shared by many. As one netizen remarked: “Aren’t we all trying to make ourselves more attractive? Ironic how those people who are bashing her as ‘discontented’ are wearing makeup in their profile pictures.”

Shiryl’s case, just as the ones that came before her, should not end as a blame game; neither she nor the health professionals should be prejudged. As Dr. Jose Joven Cruz, a longtime plastic surgeon in the Philippine General Hospital, reminded me, there are four factors that could have gone wrong: the patient, the healthcare providers, the facilities, and the procedure itself. Was the performance of three procedures warranted? A thorough investigation should consider all these before we jump to conclusions.

But beyond the case, it should lead to a broader look at how various aesthetic procedures and products go unregulated—from glutathione injections to nose jobs—and how many unlicensed individuals and clinics are able to engage in this lucrative industry. Alas, as Dr. Cruz says, we don’t even have data about how many cosmetic procedures go wrong precisely because of this lack of regulation.

Moreover, it should also lead to a consideration of why people undergo plastic surgery in the first place; we cannot dismiss it as mere vanity. The fact that Shiryl sold beauty products—and that Ellowe aspired to be a model—meant that for these individuals, a more attractive appearance can lead to economic advancement. In our service economy where “pleasing personality” is a euphemism for attractiveness, beauty can indeed be “body capital” that leads to various opportunities.

Then there’s the psychological dimension: mental health issues that surround the decision to pursue plastic surgery, and on the other hand, a seemingly legitimate pursuit of self-esteem and confidence. Or even just “normality,” as a patient once told me: “I don’t want to look beautiful. I just want to look normal.”

Finally, lest we forget, our preference for foreign—mostly Western—beauty standards deserves further unpacking.

These contexts, however, should not detract from the responsibility on the part of the providers of beauty products and services in managing clients’ expectations, informing them of all possible risks, and upholding the highest standards of safety. Regardless of their reasons, everyone deserves a chance to wake up from plastic surgery and be able to look at themselves in a mirror.

Originally published in the Philippine Daily Inquirer on April 6, 2017: http://opinion.inquirer.net/103012/plastic-surgery-goes-wrong

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. 

“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.

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.

Statement of purpose: From Medicine to Medical Anthropology

by Gideon Lasco, MD

As a Filipino doctor, one of the most important questions I see is this: For a Filipino, what does it mean to be healed? As medical student and then as a full-fledged physician, I have offered cures for countless patients, but treatment is one thing, healing is another. Why are traditional healers so effective in making their patients satisfied, to a point that a substantial number of patients go to them instead of going to hospitals? Could these healers be tapping into a therapeutic way that, though unknown to physicians, resonates well with patients and their expectations?

In the larger context, what does it mean to improve health care in the Philippines? Universal Health Care is emerging as a sought-after direction in our country's health care. But will universal access to health care translate to a health care that is responsive to the felt needs of the people? Who defines what is 'health care' in the first place? Although I am part of the Universal Health Care Study Group as a writer, researcher, and advocate, I believe that the cultural perspective must have a voice in this debate; if we are to move on to Universal Health Care, we must move to one that is culturally relevant.

Medical anthropology, I believe, can help me join the growing (and timely) search to find answers to these questions. My personal experiences and interests led me to discover this exciting field. I have travelled around the country - from Itbayat to Bongao – first as a travel writer and mountaineer, and then as a researcher interviewing indigenous healers. The intrepid and inquisitive spirit I have developed in all these travels and adventures will help me confront, and then push beyond, our understanding of culture and health in the country. If it requires travelling to far-flung areas - or immersing into marginalised sectors of our society - then I shall welcome it.

As a doctor, my calling is to heal and I am convinced that for healing to take place, one must first understand. This is my clinical motivation for pursuing medical anthropology: The awareness that the pursuit of it has the potential to improve health care in the country; it is at least as important for health as a research scientist's latest discovery about the human DNA, or a clinical researcher's innovation on a surgical technique. And, to use medical terminology, since medical anthropology enables understanding and understanding leads to healing, I contend that medical anthropology is a field that is both diagnostic and therapeutic.

In my fieldwork around the country, interviewing traditional healers, I am reminded of a divining ritual called 'pagtatawas', in which the healer makes the sign of the cross using ‘tawas’ (alum crystal), cooks it, and interprets the finished, molten product. "What comes next?" I asked. The healer answered: "Nothing. That's it. That's the treatment." For them, treatment consists of the patient being shown what happened to him or her, what caused the illness. Diagnosis and treatment are seen as one; for the patient, to understand is to be healed.

There is no magic in traditional medicine. But it deserves to be taken seriously because it is taken seriously by the people. My task as a future medical anthropologist is not to glorify or reject traditional or Western medicine, but to study them, and in studying them, find ways to apply the lessons to our health care. My field will not be the villages alone, for there is as much culture in the hospitals as there is in the far-flung areas; both are valid foci of study, both realms will tell us a lot, and I yearn to be part of the growing (and much needed) interest in making sense out of them. If we follow through, from listening to understanding and then to applying what we’ve learned, then medical anthropology would not only be clinically relevant, but also relevant to the people (which I see as the ultimate end of research, whether in the social or empirical sciences).

This is the 'medicine' that I hope to someday offer the Filipino people; the perspective that I hope to bring to the body of scholarship. I strongly believe that medical anthropology is much needed in our country, and that my experiences, interests, and advocacy can find unity in this field. Thus, I am committed to pursue a career in Medical Anthropology.

Manila
June 13, 2011