[Symposium Presentation] Coping with COVID-19: A Comparative Study on Cultural Immune Systems - Osaka, Japan

On March 4-5, 2023, I participated in an international symposium titled "A Comparative Study on Cultural Immune Systems" in Osaka, Japan, hosted by Japan's National Museum of Ethnology. As the organizers put it, the symposium aimed "to compare and analyze the ways in which the “cultural immune system” has been activated in response to COVID-19 in various Asian countries such as Japan, China, South Korea, Mongolia, the Philippines, and Bangladesh, and also consider other regions like Europe."

In my presentation, I talked about the ways in which certain COVID-19 cures figured in the ways political actors in Asia responded to the pandemic, in what I call "pharmaceutical messianism", with the following abstract that builds on my work with my research associate Vincen Gregory Yu on the subject: 

This presentation surveys some of the miracle cures or wonder drugs that were touted to treat or prevent COVID-19 in Asian countries - and analyzes the ways in which politicians and other prominent public figures in the region promoted them. While the phenomenon of ‘pharmaceutical messianism’ (Lasco and Yu 2022) has been described all over the world, this presentation also reflects on the particularities of Asian contexts that lead to the social and political efficacies of these products, regardless of their biomedical efficacy.

I would like to thank the organizers in Minkapu, including Ippei Shimamura and Sohee Che, for organizing the event and for inviting me to be part of it. 

[Workshop] Pharmaceutical becomings, Tokyo, Japan

TOKYO - Upon the invitation of Prof. Yosuke Shimazono of the University of Osaka, I came over to Japan to join a workshop entitled " “Pharmaceutical becomings: Emerging subjectivities in the age of pharmaceuticalization". Held in AEON Compass, Yeasu Conference Hall,  the workshop's other speakers included Prof. Shimazono (Osaka University) who talked about the use of immunosuppresants, Junko Iida (Kawasaki University of Medical Welfare) who discussed palliative care, and Miho Ushiyama who reflected on the 'de-pharmaceuticalisation' of people who refuse to use steroids to treat atopic dermatitis.

The abstract of my presentation, which was about height and growth supplements in the Philippines, is as follows:

In the Philippines, a class of vitamins and nutritional supplements that are growing in popularity are those that are colloquially known as pampatangkad (height enhancers) or ‘growth supplements’. Marketed for children and teenagers and imagined to contain “hormones” or “growth factors”, these products contain the legal disclaimer that they have “no approved therapeutic claims”, but their imagery - of measuring sticks, teenage basketball players,  young beauty queens, and scientific terminology (i.e. “Chlorella Growth Factor”) reinforce the perception that they are pampatangkad.

My presentation seeks to make sense of these products’ emergence and popularity in the Philippines - as part of a broader study that looks into how height figures in the everyday lives of young people in the country. My first insight is that these  products are involved in the ‘co-production’ (Jasanoff, 2003) of the notions of height: they not just reflect, but also reinforce, the meanings and materialities of tallness and shortness in the Philippines. Imagined or real, however, the efficacy of these products requires a conceptual framework, and this is accomplished by the reification of the idea of a “hormone” in popular imagination.

Interestingly, the panelists say that they do not see the same pervasiveness of the value of tallness in Japan, citing anime and TV shows that depict smaller people defeating big enemies, and the absence of height requirements for jobs. Surely, a comparative survey of the meanings of height in the region (and globally) would be a very fascinating research direction.

[Second Opinion] "Dahan-dahan sa dahon-dahon"

by Gideon Lasco
Philippine Daily Inquirer 

We Filipinos have a rich heritage of herbal medicines. Long before Dr. Nelia Maramba’s pioneering research and the Department of Health’s “Sampung Halamang Gamot,” Filipinos have been using herbs as remedies. In my own research, I encountered pine needles being used for contraception in the Cordilleras, kamangyan as treatment for asthma in Leyte, and the popular tawa-tawa for dengue all over the country.

In some way, this is good because many of our common ailments do not really require medication. Most cases of cough and cold, for instance, will get better even without any treatment, and patients end up attributing their recovery to whatever they were taking — be it an antibiotic, a vitamin, or an herbal medicine. Moreover, beyond a placebo effect, many herbs have very real benefits, as more and more scientific research is revealing.

But our soft spot for herbal medicines is being capitalized upon by various companies to sell all kinds of products. Some of these products actually have very little “herbs” in them: Dr. Bryan Lim, an infectious disease fellow at the Philippine General Hospital whose quip inspired the title of this piece, laments that some “herbal” powders promising to treat diabetes actually make it worse because they’re mostly sugar.

Others, while having actual herbs, are marketed as wonder drugs that can cure all kinds of diseases. Despite disclaimers of having “no approved therapeutic claims,” these products often come with implicit and explicit claims that even some radio newscasters attest to: a different way of being bayaran.

What’s more worrisome is when these herbal products are being presented as cures for serious conditions, particularly cancer. It is bad enough that patients are made to pay for unproven therapies, but what makes it worse is when these products take patients away from proven treatments that could have saved their lives. Any kind of therapy has an opportunity cost, which is often missed out in people’s decision-making processes.

Finally, there is also a chance they can cause actual harm. Contrary to the public’s perception that herbal medicines are largely harmless, they can be overdosed — and they do have side effects. Herbal supplements, considered technically as “food” but are often taken as medicine, remain a regulatory grey area, making it hard to ensure safety.

The appeal of herbs, of course, comes from the long-held idea that “nature heals.” To a certain extent, there is truth to this: A nutritious diet, coupled by a healthy lifestyle, can certainly make a big difference to our health. The industrialization of food and today’s sedentary lifestyles, on the other hand, have undeniably contributed to the rise of noncommunicable diseases.

But we must also bear in mind that the past was no Garden of Eden. Even when everything was “organic,” people had cancer, and it cannot be denied that modern medicine, with its vaccines, antibiotics, and novel technologies, has saved millions, if not billions, of lives.

On top of this discourse of “natural vs. artificial,” the appeal of herbs lies in the power of testimony. For scientists to be able to say something conclusive, they demand rigorous clinical trials—not just anecdotal evidence or animal studies. For many, however, a blog post can be more convincing—and celebrities more authoritative. Desperation, of course, can predispose people to cling to false hopes.

Having said all that, I have to stress that we should be open to the potential of herbal medicines, and thus support further research to validate their uses. But what we should be against is making false claims and raising expectations as to what they can do. Toward this end, government agencies and medical societies should be vigilant and critical in the way certain products are advertised. (This, by the way, also applies to pharmaceuticals — but that’s for another piece.)

Meanwhile, we must strive to create an environment of critical thinking: one that will empower the public to make informed health choices. When it comes to herbal medicines—as with all kinds of promised cures — a dose of healthy skepticism will go a long way.

Originally published in the Philippine Daily Inquirer: http://opinion.inquirer.net/105378/dahan-dahan-sa-dahon-dahon

[Second Opinion] More expensive in the Philippines

by Gideon Lasco 
Philippine Daily Inquirer

For music fans, Coldplay’s recent Asia tour was a reminder that it’s more expensive to attend live concerts in the Philippines than in other countries. My friend who went to Taipei pointed out that the expenses for her trip—hotel, airfare, and a VIP ticket—came out even cheaper than buying an equivalent ticket in Manila.

I could live without watching Coldplay in Manila and, I imagine, so could most Pinoys. But it is not just music concerts that’s more expensive in the Philippines; I worry more about those that are closer to our everyday lives.

Medicines, for instance. I cannot forget the account of a lymphoma patient when I was training in the Philippine General Hospital: The patient’s family members would fly to India just to buy Mabthera (Rituximab); it was cheaper to go there—airfare and all—and buy the drug for around P30,000 a vial, than to buy the same vial here for P90,000.

Today, a 20-milligram tablet of Adalat (Nifedipine) costs around P40 in our drugstores—but the exact same brand or preparation only costs P2 in India and P5 in Malaysia: a dramatic difference for hypertensives who take it daily. Despite the passage of the Generics Law, pharmaceuticals in the country—branded and generic drugs alike—remain among the most expensive in Asia.

Then there’s electricity: We have one of the highest power rates in the world. Despite our vast potential for clean energy—geothermal, hydroelectric wind, solar—the fact that our power rates are second highest in Asia is both ironic and tragic, even as the mothballed Bataan Nuclear Power Plant continues to mock us.

Telecommunications, including internet, are also pricier in the Philippines. In Singapore, MyRepublic’s monthly plan for 1 Gbps costs around P2,100; Globe Telecom offers a similar plan for P9,499.

Finally, tax rates in the Philippines are also among the highest in the region. If your annual income is P500,000, the tax rate here is 32 percent compared to just 10 percent in Malaysia and Thailand. That the Duterte administration is looking at tax reform is a welcome step—but what of reforms in the pharmaceutical, power, and telecommunications sectors?

In an Esquire Philippines article, Maan d’Asis Pamaran explains the steep price of the Coldplay tickets by drawing from an industry insider. She writes of a baffling host of fees: On top of bringing in the artists, securing a venue, and giving royalties to local music associations, “there is also an entertainment tax, a local government tax, working visas—and yes, believe it or not, barangay and police clearance!”

In a way, a similar piling up of costs can also explain the steep cost of medicines. As a longtime regulator tells me, the high prices are not just because of the manufacturing and research, but also because of retailers who pursue profit maximization, celebrity endorsers, ads with catchy jingles, a battalion of medical representatives, and, of course, doctors, some of whom are provided incentives (free meals and conferences abroad): an inconvenient truth for the medical profession.

As for electricity, experts point to the privatization of power (beginning in the late 1980s and culminating in the Epira Law in 2001), kilometric red tape, as well as our lack of energy diversity, among the reasons for high cost. Alas, the overlapping oligopolies that control our power and telecommunication sectors have done nothing for our cause, even as they themselves have earned massive profits.

Unfortunately, we have taken the high cost of these things for granted. When a poor family cannot afford medicines, we think it is because they are “poor,” forgetting that it can very well be because the medicines are expensive—unnecessarily so. We have gotten so used to Meralco’s price hikes that only groups like Bayan Muna routinely react to them with outrage.

Moving forward, I think we need to first realize that this is not normal; we need to get to the bottom of why this is so—and hold to account the people who have benefited from the status quo. The ensuing loss of competitiveness, and more importantly, the toll on ordinary Filipinos, is a price we shouldn’t have to pay.

Originally published in the Philippine Daily Inquirer on May 4, 2017: http://opinion.inquirer.net/103710/more-expensive-in-the-philippines

Brief comment: Efficacy in the hands of clinical trial participants

by Gideon Lasco, MD, MSc

"...it is not only medical professionals who are determining the efficacy of these pharmaceuticals. So too are the individuals enrolled in the trial. Any pharmaceutical or medical product will most likely only be used if people consider it to be effective and appropriate." - Gelling medical knowledge: innovative pharmaceuticals, experience, and perceptions of efficacy (Saethre and Stadler, 2009) 

In their paper, Saethre and Stadler (2009) give voice to participants in a clinical trial of a vaginal microbicidal gel in South Africa, saying that these participants and their partners ascribe various parameters to the gel independently of and prior to the establishment of the gel’s effects by the scientists, and regardless of what they were actually getting – the gel itself or a placebo. These parameters, they suggest, draw on local notions of gynecology and physiology, as well as their own ‘felt’ experiences of using the gel.

Theoretically, there is nothing new in this concept of efficacy that has been conceptualized and applied in various settings (Etkin, 1988; Tan, 1999; Nicther, 1995 to name a few examples). As Whyte, van der Geest, and Hardon note: "In real life, efficacies are assessed not by pharmacologists but by social actors." However, the innovativeness of this paper lies in its application of notions of efficacy to clinical trials, which are interesting because they are the site of first contact between novel products and lay individuals. In a more applied and collaborative research, Pool (2011) looks at clinical trials as ‘cultural trials’, asserting the importance not just of controlled measurements but also what the patients feel about the drug in evaluating new pharmaceuticals. Montgomery and Pool (2011) echo the same rationale, essentially calling for ‘representation’ in the process of developing drugs for prevention.

The benefits of this ethnographic voice in making drugs ‘better’ make me reflect on the role of anthropologists in the pharmaceutical industry in general, mindful of the underlying political economy. What guideposts do anthropologists have in this kind of work? How do we draw the line between the anthropology of pharmaceuticals and anthropology for pharmaceuticals?

Amsterdam
October 2013

Pills, potency and fertility: The illicit trade of male sexual enhancement products in Quiapo, Manila

by Gideon Lasco, MD

In a paradoxical and very graphic juxtaposition of the sacred and the profane, the Minor Basilica of the Black Nazarene in Quiapo, Manila – popularly known as the Quiapo Church – is surrounded by peddlers selling all sorts of products, many of which act as 'pharmaceuticals', in the sense that they are invested with notions of efficacy and potency in effecting cures and enhancing bodies. Given its “medical” function, anthropologist Michael Tan has aptly christened it the “Quiapo Medical Center” (Tan, 2009). He emphasizes the temporal dimension in his lectures about Quiapo, saying that “it changes every time.” (personal correspondence).  

Considering its reputation for selling products that are outside the sanction of the law, the church, and the medical establishment, I decided to focus on enhancers or male potency and fertility, which is one such gray area. I, together with my research assistant Ryan Tuiza, visited Quiapo several times from August to September 2012 to identify which products are sold for male sexual enhancement, to describe how they are sold, and to whom. I was also interested in how the vendors describe their products. 

Ideally, we ought to have embarked on survey of which products are sold for sexual enhancement across genders (heterosexual males and females, homosexual males and females). However, we were limited by our own genders, which, as we found, made it difficult to relate to products that were not deemed appropriate for our use. Moreover, as we observed during our field work, the Quiapo vendors are very suspicious of the people who pass by, even as they offer their merchandise with spiels such as:



Para saan po? (For what?)
Ano ang hanap nyo? (What are you looking for?) 

The first question is interesting because it invites an answer based on the [pampa + x form], which denotes function. e.g. pampaalis ng lagnat (Remover of fever), pampalaki (Enlarger). After the initial visits, we decided to come up with our own opening spiels: 

“Naghahanap po ako ng pampagana sa sex...” (I'm looking for a mood-enhancer for sex..."“May pampa-buntis po ba kayo?” (Do you have something to make someone pregnant?)

These two spiels also reflect the two categories of substances we were looking for, enhancers of potency, and enhancers of fertility. In this short note, I will describe several products that are used for these purposes. Later on, I will continue to reflect more on our Quiapo experiences by offering thematic insights. 

ENHANCERS OF POTENCY

In this category, I use the colloquial usage of the term potency, i.e. male sexual performance. In the context of Quiapo, the attributes of potency – which are also seen as effects of the products – including “harder” and “longer” penile erections, greater physical stamina during sex, and faster “recovery time”. 

1. “Peter Cream” – This white cream from China is said to be a very potent enhancer of sexual performance. The container of the cream is illustrated with Chinese characters, with only “Peter Cream” in Latin letters. We do not know whether the naming of this product has something to do with 'peter' being a slang term for penis in countries like the United States. The effect is described in vivid detail:

Kapag pinahid mo yan, titigas agad yung ari mo. Makakaramdam ka ng kakaibang init... tatagal ka ng tatlong oras, at kahit 5 rounds kayang-kaya. Maaawa ka sa babae. (If you apply it, your penis will become erect. You will feel a strange heat. You will last for three hours, and even 5 rounds is easy. You will pity the woman.)

The peddler is so confident about its efficacy that he even invited us to try it to feel the effect. He adds that he himself uses it, and so does his old uncle. “This is popular with the old men,” he says.

The cream is applied just once, and the effect should be experienced within five minutes. For maximal effect, it is advised that the man takes a shower first before he uses it. 

Peter Cream is sold in different quantities, with ¼ of a container selling for P200, and the whole for P500. 

2. “Five in One” - This tablet is said to combine five different types of desire-enhancers (“pampagana”). Like Peter Cream, it also produces body heat (“nag-iinit ang katawan”) and the effect is seen after five minutes. For maximal effect, the stomach must be full before this is taken. 

Also, testimonials were invoked when the vendors try to sell this product. Depending on the number of tablets, it is sold for PHP 300 -500. 

3. Lana ng ahas (Snake's oil) – This is a panacea that is being offered more openly by the vendors: it is said to cure a myriad of conditions, from “anemic” to rheumatisms. According to one vendor, having it massaged on your body will stimulate heat (i.e. pampainit) which is also a form of sexual stimulation (i.e. pampagana), and is effective for both men and women. 

4. Dugo ng cobra (Cobra's blood) – This is a kind of snake wine allegedly with the blood of cobra on it, and is also said to enhance sexual performance, among other aspects of masculinity (i.e. pampalakas sa trabaho, energy-booster at work). Placed in recycled bottles of Tanduay rhum and other local liquor, you can see the body of the snake inside the bottle, and the liquid is amber-colored. Other bottles have the added ingredient of ginseng, which is also a known Oriental aphrodisiac. It is to be drank an hour before sexual intercourse to have full effect. 

5. Viagra (Sildenafil) – According to at least one vendor, Viagra tablets are also “available”, and interested buyers are asked to wait for 30 minutes. This was picked up by my research assistant, but unfortunately, we were not able to pursue this lead. There is also no way of ascertaining whether the alleged 'Viagra' tablets are authentic. Nevertheless, even with incomplete data, I am including it here for its mere existence is a significant finding.

To recap our rundown of enhancers of Peter Cream and “Five-in-One” seemed to be the most popular options, and are offered by several vendors, but these products are hidden from view, and are covered with manila paper. The herbals, on the other hand, and the oil and wine bottles, are displayed prominently along with amulets, candles, and sachets of leaves. Western medicines, represented in our survey by Viagra, may also be more available than previously thought. 

ENHANCERS OF FERTILITY

In this section, fertility is used in its biological sense, that is, the “natural capability to produce offspring”. We found that there are also products in Quiapo that are being sold for this specific purpose:

1.”Root crops” - This is a liquid concoction sold in bottles, and is said to be made of roots, bark that were mixed with vitamins which serve to “revive the sperm cells”. The vendors say it is made in China. 
It is said to have an effect as soon as one week, and should be taken thrice a day before eating.

According to one vendor, many people have already tried it, and they can attest to its efficacy. He told the story of a couple who failed to conceive after five years of conjugal union. They tried all sorts of cures, but in vain, until the husband started using the root crops. In just two months, the woman got pregnant. 


However, this special liquid formula comes with a steep price: P500 for a small bottle (around 50 mL) and P1000 for a bigger one (100 mL).

2. Vitamix tablet – Other vendors offer “Vitamix Plus” as a cure for infertility. It is to be taken twice or thrice a day before meals, and takes two weeks to a month to take effect. There are no contraindications to its use, and it is sold for P1000-P1500 per blister pack.

Unlike the other products, this one was amenable to further inquiry by searching for “Vitamix” in the Internet. Curiously, although the vendors say it is made in China, the online search identifies its source as an Indian pharmaceutical firm. 

INSIGHTS 

1. The eclecticism of Quiapo – I was honestly expecting to see indigenous and traditional products to come up – the traditional expectation of Quiapo – but a majority of the products we saw were ascribed to China, although we also saw that this does not necessarily mean that the true source is China. Regardless of the origin of these products, however, there are regulatory implications of this trend. More so when 'Viagra' comes up as one of the consumer choices. Three different medical systems are represented in Quiapo: Chinese, Western, and Filipino traditional, and seemingly, all are beyond the reach of regulation.

2. A vast referral system. To follow Prof. Tan's language, “Quiapo Medical Center” is a 'tertiary hospital' with a vast network of specialists, which ironically leads back to the medical profession. The offer of a referral to a doctor, coming from a Quiapo peddler, is demonstrative of the complicity of at least some health professionals. My research assistant also recalls being offered pamparegla in case his girlfriend needs it, hinting at other services: 

May malalapitan tayo ng tulong kung kailangan nyo ng pampalaglag...
(“There are people we can ask for help if you need an abortifacient”)

3. Suspicion and surveillance. Perhaps as an adaptation to the efforts to curb the trade of illicit products, the vendors are visibly suspicious of passersby, and even those who claim to be looking for products. Personally, I felt that I was not able to fully act out the role of a “typical” customer looking for sexual enhancement, or a cure for infertility – hence my strategy of getting a field worker. As if to affirm the existence of the illicit trade, banners surround the Quiapo church warning the public that the trade of abortifacients like Cytotec will be dealt with severely (Postrado, 2009). However, even when these government moves are met with success, there are many other products out there that require regulation and control. 

4. The power of testimonials. To boost their case for their products, vendors usually invoke supposed testimonies of their past customers. The image of an old man, does a lot to boost their case, particularly in the absence of any objective parameter to evaluate the products. Pit against the “evidence-based” medicine of health professionals are the “anecdote-based” medicine of the vendors, which actually appeal more to the public.

CONCLUSION

There exists in “Quiapo Medical Center” a market for products that promise to enhance male potency and fertility. Sold at relatively high prices, these products likewise suggest that there is a substantial the number of people who are willing to buy them, and vendors are quick to offer connections to medical practitioners, suggesting that the "biomedical sector" and the "informal sector" of health care not parallel systems; there are links between them.

With little or no product information, it is not just efficacy, but safety, that is a major concern as far as these products are concerned. Viagra was initially a drug for pulmonary hypertension until  male study volunteers discovered its "desirable" side effect. But this goes to show that these products have systemic effects that can very well be harmful to its users, especially the elderly who are often the target of these drugs. Health authorities should take this matter seriously.  

Made in China, banned in the Philippines, and sold without regulation, these products reinforce the view that “you can buy anything in Quiapo.” If its vendors are to be believed, the price of pleasure ranges from 200 to 500 pesos, “satisfaction guaranteed”. 

Manila

September 2012

REFERENCES

Tan, Michael. “Quiapo Oracle”, opinion article, Philippine Daily Inquirer, January 1, 2009. Available at: http://opinion.inquirer.net/inquireropinion/columns/view/20090109-182286/Quiapo-oracle

Chua, Philip. “Is street Viagra safe?”, opinion article, Cebu Daily News, January 19, 2009. Available: http://globalnation.inquirer.net/cebudailynews/opinion/view/20090119-184254/Is-street-Viagra-safe

Postrado, Leonard. “Quiapo vendors warned anew”, news article, Manila Bulletin, August 15, 2009. Available: http://www.mb.com.ph/articles/216062/quiapo-vendors-warned-anew

Drugs, supplements, and Universal Health Care

by Gideon Lasco, MD

Attaching the word "universal" to "health care" is far more difficult in real life than in paper, for it involves reconciling the oftentimes disparate interests of various stakeholders. This is where regulation comes in: it tries to balance these interests while ensuring quality health care that is safe, equitable, and affordable.

In the ongoing “Secretary's Cup”, a series of talks, debates, and town-hall meetings organized by the Department of Health and its partners, "regulation" is highlighted as one of the six building blocks of Universal Health Care (UHC).

One of the key themes in regulation is the management of health products or medicines. From antibiotics to vitamins, drugs are part of our everyday lives, and we see them as fundamental mediator of health and wellness in our bodies. In this article, we examine areas where regulation is most needed.

Generics and branded drugs
The prices of medicines in the Philippines rank among the highest in Asia. In response to increasing demand for cheaper medicines, the Philippines enacted laws in 1988 and 2008 promoting generics, and parallel importation of branded drugs.

The results have been mixed. Today, generic drugstores are ubiquitous, and government-run Botika ng Barangay outlets cater to many communities. On the other hand, many people continue to distrust generics. A significant number of doctors share the view that inasmuch as they want to support generics, they do not wish to entrust their patients' health on generics that they say are of doubtful efficacy.

This is where regulation comes in. With sufficient credibility, the Food and Drug Administration (FDA) can narrow the perception gap between branded and generic drugs with its pronouncements of safety and efficacy.

Meanwhile, Ponstan, a pain reliever, costs less than two pesos in India and almost 16 pesos in the Philippines. Bactrim, an antibiotic, costs just 56 centavos in India and P18.16 in the Philippines.

Drugs and food supplements
Another important regulatory concern involves “food supplements”. In theory, they are not drugs, freeing them from the stringent requirements for drug approval. But in practice, they are marketed as drugs and treatments for particular conditions, notwithstanding the obligatory disavowal that follows their TV advertisements: “No approved therapeutic claims”.

These supplements fulfill people's needs that are not dealt with or sanctioned by the medical establishment, such as skin whitening and weight loss. Other supplements also promise to treat conditions such as cancer, diabetes, heart disease, whose treatments would be far more expensive if availed of from conventional medicine.

There are serious issues of safety among these products. As 'non-drugs', the ingredients of these drugs have not been examined thoroughly. They may contain harmful ingredients, and at high doses, they might be toxic to the body, unbeknownst to their adherents. For instance, comfrey, an herbal supplement widely promoted in the 1990s, turned out to be potentially harmful to the liver.

Moreover, there is also the issue of opportunity cost: If a patient takes a supplement to treat his or her cancer instead of going for chemotherapy, and in doing so, forfeits the opportunity to avail of life-saving treatment, who is to blame? Ultimately, it is the government's responsibility to ensure that consumers make informed choices. It must examine the way these products are marketed. Therapeutic claims, explicit or implicit, must not be advertised unless validated.

Traditional and modern medicines
Related to supplements, there is a challenge of integrating (and regulating) traditional remedies, particularly herbal medicines. In the early 1990s, the DOH led by Dr. Juan Flavier embarked on a campaign to promote herbal medicines as remedies for common ailments such as cough, culminating in the promotion of the “Sampung Halamang Gamot” (Ten Medicinal Plants). Lagundi, one of the ten, has been well-researched and the University of the Philippines National Institutes of Health has endorsed its efficacy and safety as a cough remedy.

Traditional and modern medicines should be treated equally by regulators. Herbal medicines, despite their being “natural”, must be evaluated for possible side effects and toxicity. But as lagundi has demonstrated, it also has the potential to be at par with other medicines in terms of effectiveness, and thus, they need to be taken seriously. Considering our wealth of plants and healing traditions involving plants, further research is needed to validate their therapeutic (and economic) potential.

Conclusion: Medicine and medicines
In this article, we looked into dynamics of branded and generic drugs, drugs and 'supplements', as well as traditional and modern medicines. In managing these relationships, it is the responsibility of the regulators, such as the FDA, to protect the interest of consumers. Moreover, in the larger framework of health reforms, it is important to recognize that universal access to Medicine should always be accompanied with universal access to medicines that are safe, effective, and affordable.

Manila
September 14, 2012

REFERENCES

Pizaro, O (2011). “Review of the Cheaper Medicines Program of the Philippines”. Philippine Institute for Development Studies. Available at: http://www.dbm.gov.ph/wp-content/OPCCB/fpb/b_DOH-CheaperMedicines/i-Cheaper%20Medicines%20Program%20Review.pdf

Lizada (2007). Food Safety in the Philippines. USAID. Available at: http://www.scribd.com/doc/4938633/Food-Safety-in-the-Philippines-Problems-Issues-and-Opportunities-for-the-Small-Farmers-and-Produ

Noni juice and the vulnerability of the Filipino to anything 'herbal'

by Gideon Lasco, MD

In the 1990s, juice from the noni fruit (Morinda citrifolia), popularly known as "Noni juice" became a very popular product with its promise as a panacea or 'cure-all', with purported benefits ranging from cancer cure to increased vitality. Until now, this product lingers in some drugstores and is still being marketed in the Internet as a wonder supplement. However, this fad has been replaced by subsequent others - such as mangosteen and mahogany seeds.

The trend we observe is that first, a product emerges in public consciousness by word-of-mouth and heavy marketing. When this word-of-mouth streams to the level of households, a lot of people, particularly women and those in the older age groups would patronize it. Only after several months or years in which the promised claims have not materialized will people discontinue buying these products. By then, the unwitting family would have lost thousands which could have been used for proven "wellness" therapies such as vaccines. By then, the company that sold the product would have made enough profit to move on to promote the next herbal superstar.

In the case of noni juice, a close examination of its nutritional content reveals that the micronutrient (i.e. vitamin and mineral) content of a noni fruit is just similar to that of a raw orange. All its claims were not substantiated by numerous experiments and trials.

Here an interesting observation is seen: while scientific inquiry puts more emphasis on evidence derived from experimentation and tends to ignore anecdotal evidence, the public is actually more likely to listen to anecdotes of healing. For them it is more tangible and more believable that Neighbor Juan dela Cruz had a tumor that disappeared after he drank noni juice compared to a randomized-control trial of several hundred participants drinking noni juice that found no evidence of its efficacy against cancer. Only "personal experience" is weighed heavier than "anecdotal evidence" by the people, hence, only after months of experience of benefit (or lack) will they decide to continue or discontinue a product. This hierarchy of evidence means that Western medicine still has a lot of steps to take in winning the trust of the public. 

Paradoxically, any highfalutin or scientific-sounding name such as "L-Carnitine" also gets high marks from the public. But this is the topic of another essay.

The vulnerability of Filipinos to anything 'herbal' may be traced to our folk medicine heritage. Long before Western medicine arrived in our shores by way of Spain and America, our ancestors sought ways to cure our illnesses and ailments. As in many other cultures, they looked to the plants and trees in our forests. Some proved to be effective and have since been validated by scientific experiments. Regardless of scientific evidence, however, we value these homegrown efforts to cure our ailments. We have a deep cultural, emotional attachment to these therapies, perhaps reminding us of lola brewing oregano or lagundi leaves as treatment for cough.

It is not just our cultural heritage that makes us sympathetic to herbal products. The modernist ideal of going back to nature, which has its roots in New Age philosophy and a heightened attention to health and the body, has also lent its support to herbal products, vis-a-vis the 'artificial' pharmaceuticals. 

Businesses, particularly ' nutriceutical' companies, can abuse this emotional attachment to herbals by invoking them heavily in their marketing campaigns and sensationalizing the range and potency of their therapeutic effects. The disclaimer "No approved therapeutic claims" cannot compete against images of healing that advertisements portray. This is what we see now. There is need for legislation to curb this, as well as public information campaigns to counteract the unopposed one-sided information in favor of these herbal products. 

The rationale for legislation, as well as public information campaigns, is this: there potential harm in using in 'herbal medicines'. Being pharmacologically active substances, just like any other drug they can lead to overdose, toxicity and poisoning, as well as allergic reactions. Since a doctor usually asks a victim of overdose if he or she has ingested any drug and people don't classify these herbals as such, these cases usually go undocumented or undiagnosed. It must be conceded however that these are rare cases and most herbal medicines do not cause substantial harm to the one taking them.

A bigger danger, however, is if herbal medicines take away the opportunity for a patient to avail of medical treatment and the money to finance therapy that is warranted. For example, doctors see many cases of people consulting for cancer that has already reached Stage IV (the cancer has spread to other parts of the body). When asked why it took a long time for them to seek consult, it is not unusual for patients to say that they decided to first try out a particular herbal supplement. But when the tumor continued to grow, that was the time when they decided to finally consult. Here's the rub: Stage I or II cancer if detected and treated early usually has good prognosis, with a growing number of cancer survivors even living healthy lives and normal lifespans. Stage IV cancer usually kills within several months or few years.

On the positive other hand, emotional attachment to herbals can be used in a healthy way. It could win public sympathy for the research and development (R&D) efforts to identify, develop, and market herbal medicines and that work. This thrust has the potential to reduce our dependence on the mainstream pharmaceutical industry. Cough syrups, many of which are themselves not backed by scientific evidence, are better replaced with a nice brew of lagundi leaves. The Department of Health in 2003 and 2007 launched campaigns for the "Sampung Halamang Gamot" but this is largely under-utilized. 

That we have a wealth of ethnopharmacology is clear. In 1949, soil from Iloilo was isolated to have metabolic products that served as the precursor of Erythromycin, a very important antibiotic and Filipino scientists continue to research on the potential benefits of various plants. The late National Scientist Dr. Conrado Dayrit pioneered research on Virgin Coconut Oil and studies are beginning to show its benefits in various ways. It is already routine practice in the Philippine General Hospital to include VCO in the nutritional upbuilding of admitted children in the Pediatrics wards.

The legacy of our herbal healers has definitely persisted to the present time. It remains to be seen if it will ultimately be for the profit of some, or for the benefit of all.