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

Youngblood: Doctors and 'hilots'

by Gideon Lasco

(Note: This essay was published in Inquirer's 'Youngblood' column on October 12, 2010)

THE SEARCH for cures is one of the most important struggles of man. We have always endeavored to find ways to treat the illnesses afflicting humankind, be they biological, social, political or spiritual. We look up to doctors because they hold the promise of a cure. However, even before the arrival of Western medicine, our people already had their own ways of dealing with health problems. This collective experience combined with present-day medical science shapes the way we deal with our health.For our community immersion, my blockmates at the University of the Philippines College of Medicine and I spent six weeks in San Juan, Batangas. We served as doctors of the barangays, conducting clinics, paying home visits and assisting in their programs. More significantly, we lived with the people. We were assigned to live with “Nanay Nelly,” a senior citizen who ran a sari-sari store.

At the Philippine General Hospital, we see patients in the Outpatient Department by the hundreds, and it becomes a daily struggle to attend to all of them. But in Barangay Pinagbayanan, where we only had a few patients daily, we had more time to know our patients better. So we probed deeper into their health practices. They shared, and we listened.

Asked, for instance, why they do not go at once to hospitals for treatment, they said: “Of course, we want to go to the hospital. But what if we cannot afford it? Where will we go?”

Since lack of money is often the rule more than the exception among people needing medical attention, hilots provide an alternative. They charge P20 to P50 per consultation—and the service comes free if the patient is really poor. These hilots may not be always able to cure, and indeed we see many patients in the end-stage of serious ailments after relying on hilots for too long, but they at least offer some hope for many of our countrymen. Being part of the community, these hilots treat their patients with a compassion that sometimes cannot be found in the cold, clinical setting of modern-day hospitals.

We also encountered beliefs which are irreconcilable with modern science but which people strongly hold to this day. For instance, Dr. Jose Rizal wrote that the leading causes of illness in the Philippines are “winds, vapors and rain,” and to this day this thinking is very much alive in the community. One patient who had a skin disease he believed to have acquired during a flood refused an ointment, arguing that a “wet” ailment cannot be cured by another wet substance. As a compromise, we prescribed Amoxicillin, which proved equally effective.

Our group welcomed such encounters because they helped us understand better the attitudes of our patients at the PGH, many of whom come from the provinces.

One day, on my way to San Juan after a short visit to my hometown of San Pablo, Laguna, I dozed off in the bus. When I woke up and stood up, I felt a stabbing pain shoot up from my lower back.
When I arrived at Nanay Nelly’s house, I shared my problem with everyone. She suggested that I consult a hilot who happened to be making the “rounds” at the time. (Just like physicians who make daily rounds of hospitals, hilots pay visits to patients in their communities to see how they are doing.) She proceeded to tell me stories of successful cures done by this particular hilot, including the usual tale about someone getting well in her hands after being diagnosed with terminal cancer by his doctor. Seeing it as an opportunity to deepen my immersion experience, and wishing that indeed I would get some relief from the pain, I welcomed Nanay Nelly’s suggestion.

The hilot was initially reluctant to examine me when she heard that I was a doctor. “Surely you have better drugs for this!” her face told me. But when I told her I was really in pain and needed help, she seemed to settle down.

She began by asking me when and how I got the pain and to describe how severe it was and its quality. Then she examined my lower back, palpating my spine. After a while I saw her nodding her head, apparently arriving at her diagnosis.

She proceeded to massage my back with native oil. And then she took out a plaster, wrote some words in it, and patched it on my back. When I asked what she wrote on the plaster, she said they were Latin words: “SATOR AREPO TENET OPERA ROTAS.” I noted that the words formed a palindrome much like those in Dan Brown novels.

Immediately I felt a soothing sensation, probably because the plaster contained menthol. I thanked the hilot and promised that I would keep the plaster in place until I felt better, in accordance with her instructions.

And just as doctors don’t charge their colleagues, the hilot refused my offer of payment. “Maybe next week it would be my turn to consult you,” she said with a smile.

Later that day, I was feeling better; the pain was almost gone. When I told one of my batchmates about it, he wondered whether the cure was for real or it was merely another demonstration of the placebo effect.

But what is real and who can say for sure? Belief being subjective and experience-based, it is a personal choice. I could attribute my healing to inevitability (“it will heal by itself”), to the therapy (either working through scientifically explainable or mystical phenomena), to God (working by His sheer power or through circumstance which could include any of the above) or even to myself (the power of positive thinking). Or maybe a combination of all of these. But whatever the case may be, I definitely learned a great deal from the hilot and the community.

The experience made me realize that if we could learn from hilots, albularyos and other healers, we can develop a universal, holistic, culturally acceptable health care system in the Philippines.

Gideon Lasco, 24, is a graduate of the UP College of Medicine. He passed the board exams last August and is currently a resident physician at the San Pablo Doctors’ Hospital in Laguna.

Six days of community medicine in an urban poor community

by Gideon Lasco

(Note: This is a reflection of our experience as volunteer health staff in Brgy. 143, Pasay City, as part of our medical training. I was a third year medical student then)

On our first day, we were excited to see our barangay. Ate Nene, the prominent BHW of Brgy. 143, fetched us from the LRT station. She told us that our first stop was the local health center, where we are to pay a courtesy call to the doctor. However, when we arrived there, he didn’t show up in spite of our waiting for him for over an hour. We then proceeded to the walk through the Barangay. We passed by the “Tunnel” where we saw for the first time the grim realities of the area. The tunnel’s walls and roof were patched-up shanties, stacked on top of each other; on its 1-meter wide floor the women washed their clothes, the men took their baths, the children roamed about. Everything was done in the footpath which is also the social area of the neighbors. We began to notice how politics is a significant part of the BHWs’ concerns; they introduced us to the new barangay chairman, and the outgoing Kapitan Ong, who seemed apathetic to our presences.

On our second day, we were again asked to drop by the local health center first, to pay a courtesy call to the doctor. Once again, he didn’t show up, and we insisted that we proceed to the barangay hall already. There, Dr.Portia Marcelo followed and a Barangay Health meeting was held. Foremost in the BHWs’ minds was the recently-concluded elections; they had supported the losing candidate and they were suddenly insecure about their position as BHWs. Because of these, they seem paralyzed and unmotivated. What came out of the meeting was a need to engage with the new officials, and it was agreed that they ought to make a report to present their accomplishments in the past few years. As ICCs we did virtually nothing but observe the proceedings. Only four or five BHWs were present on this day.

On our third day, we went straight to the Brgy. Hall. We checked up around 18 kids to track their health and nutrition. They are enrolled at the Supplemental Feeding Program (SFP) but due to the elections this program has been put to a halt, and it was the first time in two months that a check up took place. We found many of the kids malnourished, with dental carries, scabies infection, among others. We identified some of them for follow-up.

On our fourth day, only two BHWs were present: Ate Babes and Ate Cynthia. We were supposed to help them make their report to the new barangay officials. Perhaps their poor attendance can be related to their feeling of being ‘paralyzed’ due to, again, politics. We taught Ate Cynthia how to use a computer. Moreover, we conducted home visits to 5 kids whose special health concerns we identified the day before. Meanwhile, Kapitan Ong continued his tong-its sessions with his friends.

On our fifth day, again only two BHWs were present. Ate Babes was there, too, and we continued to help them in making their report.

On our sixth and final day, we came to help the BHWs present their final report. It was also supposedly a feedback/conclusion session. Again, very unfortunately, only Ate Babes was there.  She was disillusioned too, because she felt that she was being left alone in the struggle. It was only Ate Babes who accompanied us when we rode the jeepney and bade Brgy. 143 farewell.

From these six days, it is very apparent that the BHWs lacked motivation. Unfortunately, down to their level, political intrigue is rampant even though their positions are actually minor and petty.

Probably they are beginning to feel that their efforts are futile. However, negative attitudes are like infectious diseases, they are communicable…honestly I felt unmotivated too sometimes because we were going all the way from PGH only to meet with one or two BHWs…there wasn’t much accomplishment in that. Hopefully, when the political dust settles, the BHWs can get back to work again; there is so much that needs to be done.

It is also unfortunate that the barangay officials don’t seem to care. The Brgy. Captain just loitered around his office. How can he expect others to work if he is as lazy as that? The local health doctor exhibited a similar attitude: how can he inspire future doctors, or even his constituents, if he’s always late and doesn’t take his job seriously?

I realized also that it is not enough to see the poor from a distance, or read about their plight. Actually being there inside the tunnel and palpating the body of poverty is an experience that gives me a clearer picture of Metro Manila. There are realities within the tunnel that do not see the light of day, and these things you will never see unless you really go to these people and listen to their stories. Beneath those high-rise buildings, below those modern roads are dark tunnels. Hopefully, in the future, the people of Brgy 143’s tunnel will find their way out.

Life and the hospital: A head nurse at PGH recalls the struggles of her life

by Gideon Lasco

WHEN WE came to her one Friday morning, all eyes were on the political crisis: the president declares a ‘state of emergency’, a general gets arrested. But in the Philippine General Hospital, life goes on. No strike is possible; the men and women toil day and night, ceaselessly. The public hospital is a community of heroes, trying to heal the nation while its leaders inflict painful wounds.

Life goes on – this has been the theme of Mrs. Luningning Siarez, head nurse of the Community Medicine OPD. As her name suggests, she has a bright and ebullient personality. Approachable and talkative, like your regular ninang. She looked old for a 49-yr. old; the wrinkles of stress has weathered her face. But when we approached her, her eyes shone. As if she – head nurse of the busiest hospital in the land – had nothing else to do, she sat down and talked to us. Then her story began to unfold before our eyes.

A family of ten

Mrs. Siarez was born in Pasay City, a daughter of a driver and a housewife. Her father took the gargantuan task of breadwinning for eight children. Good thing he landed in the employ of Sen. Arturo Tolentino, but the pay wasn’t enough: to see the girls through college, the boys worked while they studied; a pig was sold and a parcel of land mortgaged.    

Sometimes, our narrator pauses – another nurse enters and reports to her. Affairs of the hospital perhaps? After all, she holds the title of ‘Chief Nurse’ and has her own office, but this, as she tells us, was hard earned. After all, she has been working at the PGH for twenty-three years!

She adds that her life back then was boring: “school, home, and church” – those three summarized her daily routine. “It’s only here in PGH that I experienced an outing – at the beach!” she exclaims.

‘My husband went to Saudi’

After surviving the hard, knock life as a youth, Mrs. Siarez was to realize that married life is even harder. Their honeymoon was still fresh in her mind when her husband had to go to Saudi to earn a living. There, he stayed for five years. “Of course it was a hard and lonely time for me,” she said. “But was there any choice for us?”

Then, from the husband’s dinars and riyals, they got themselves a small home in Calamba, Laguna, and a taxicab for her husband, but it was a hard life: as a taxi driver one has to wake up at 4 AM, and sometimes get assaulted by thugs. Instead, Mr. Siarez became an air-con technician.


Tears of a mother

It was when we asked about her family that her nostalgia turned into sadness. Mrs. Siarez told us that she earns around P18,000 as a head nurse, while his husband nets P7,000 because of so many deductions. They have a daughter enrolled as a nurse in Manila Doctors’, and the rest also studies in college and high school. All in all, the cost reaches around P80,000 per semester. “We can only afford two things – education and food. That’s all,” she sighs. “We had an insurance plan, but look at what happened. It’s all wasted,” she adds, referring to the education insurance crisis a year. “My parents give support to the kids, so does my husband’s employer”. But these, she says, are not enough. “My poor son – he may have to stop studying because we really can’t…”

She pauses and sheds some tears.

Still thankful

Countless tales, like hers, are easy to find. Just go to the streets, to the wards: the patients, doctors, nurses – everyone has a story to tell. These are tales of our people: their struggle to live in a poor country such as ours, their struggle to fulfill the needs of their loved ones. Mrs. Siarez told us that she dreamt of going abroad, but she is resigned to the fact that this is an impossible hope. “I don’t hold a grudge against life. When I see the squatters that we visit, I thank God that I am still better off. I’ve taken care of the terminally ill patients here at PGH for more than two decades, and I’m thankful that I’m still strong, that I’m able to see my kids grow. I guess that’s all.” She manages a smile.

A 49-yr. old mother, working at the hospital, struggling to give her sons and daughters a ray of hope for a bright future. There are many stories in the PGH like hers. And they are not happy ones.

Manila
January 2007