What is a rant? Reflections on social media negativity

by Gideon Lasco

Ranting is such a common behavior nowadays that many rants are devoted to ranting. In our age when expressing one’s opinion is as easy as typing a few lines and pressing a button, no one wants to be called a ranter - or a whiner or a hater - but a lot of people actualy rant without acknowledging that they are, in fact, ranting. Thus many people, overwhelmed with the negativity, are distancing themselves from Facebook; while some go on a “social media holiday”. One of my friends has even deactivated his social media accounts completely, lamenting that the world has been ran over by a “generation of ranters.”

But what, exactly, is a rant? According to the Merriam-Webster dictionary, a rant is “to talk loudly and in a way that shows anger; to complain in a way that is unreasonable.” This definition is a good starting point, telling us that a rant is a way of communicating or complaining that is (1) loud (2) angry (3) unreasonable.

How can one be “loud” in social media? The most obvious is the lavish use of ALL CAPS, but there are other ways to be loud. Making use of a photo, for instance, makes one’s message “louder” - images can be very powerful and memes are the poetry of our time. Ranting goes for the dramatic, the sensational.

As for “anger”, we can easily see this with the choice of words. Curse-words - although their currency has been grossly inflated and they don’t have the same gravity anymore - are staple fare for rants. But a rant can also incite to anger by insulting others through witticisms, name-calling, or logical-sounding arguments. Directing the anger at someone also makes it more weighty (so-called “open letters”), and ranting is at its best when it is not just angry, but accusatory.

The crucial test of ranting, however, is whether something is “unreasonable” or not, and this is where its subjectivity lies. Many Filipinos won’t say that the Philippines is ranting about the Spartlys dispute - we would think that our claims are reasonable, and our anger warranted. Neither will many consider as mere “rants” the online posts expressing outrage over repressive regimes that gave rise to the Arab Spring. As these examples show, one man’s “rant” is another’s “grievance”.

Perhaps the non-confrontational attitude of Filipinos makes social media a particularly suitable venue to express our sentiments. Psychologist John Suler termed this the “online disinibition effect”, which draws from the sense of anonymity and distance to free people from their inhibitions, thinking that there will be little backlash for what they would say.

Rants are oftentimes signs of helplessness; people do not rant if they think there are other ways to communicate their message. Indeed, ranting satisfies the need to release one’s negative emotions, while at the same time offering the chance that the addressee would actually listen. On the other hand, oftentimes enmeshed in this need to communicate is a desire to get noticed by the social media universe; the desire to go viral. Thus instead of being a last resort, it becomes the first. Consequently, it feeds a culture of outrage, where attention is validation.

***

IN THE multitide of ideas and sentiments floated on social media, there are many ways to stand out. You can inspire people with beautiful pictures, enlighten them with a well-written thinkpiece, or make them laugh with your pet’s funny expressions. Psychological studies, however, have shown that “negative emotions are more contagious than positive ones”, as Finnish scholar Harri Jalonen puts in. This “negative bias” makes it understandable that many people resort to ranting.

The criteria for reason, however, should give us pause for what we label as “rants”. While some posts are clearly rants, there simply is no objective criteria we can apply for the “reasonability” of every post. During the APEC week, when people in Metro Manila were thrown into miserable traffic conditions, I observed that the people who experienced the traffic themselves “liked” and “shared” posts that gave voice to their predicament, while those living elsewhere were more likely to dismiss them as “rants”. This subjectivity of what constitutes a rant reminds us that in the act of labeling people's viewpoints (either as rants or “painful truths”; “whining” or “telling it like it is”), we engage our own ideologies, politics, and (limited) knowledge.

We should strive to move away from a “ranting culture” by delivering our messages in a way that does not incite people to more anger. If social media is social, then we must abide by social conventions: respecting others’ points of view, not taking different opinions personally, and if called for, arguing with reason, not with anger. And if social media is media, then we are all journalists now, and if we express outrage, we must do so with a committment to truth and fairness.

As for those who are in the receiving end of a rant, we should likewise exercise restraint - as well as an openness to what might actually be a valid argument. Dismissing something as a “rant” will only inflame its source. Ranting about a “rant”, like fighting fire with fire, is equally unhelpful. The cycle of ranting, ranting about ranting, and so on, ends when someone on the receiving end of a rant reads through the rant and tries instead to find out where it’s coming from.

Do we, then, need a new set of values - in this age of social media? I don’t think so. I think we just need to bring back the old ones - starting with humility.

Manila
December 11, 2015

Health-spending behaviors: the temporal dimension of 'out-of-pocket spending'

by Gideon Lasco, MD

Out-of-pocket spending or out of pocket expenditure is defined by the World Bank as "any direct outlay by households, including gratuities and in-kind payments, to health practitioners and suppliers of pharmaceuticals, therapeutic appliances, and other goods and services whose primary intent is to contribute to the restoration or enhancement of the health status of individuals or population groups." Broadly defined, we can look at it as the percentage of total health expenditure borne by individuals and their families. OOPS is seen as a measure of the quality of a health care system: a higher OOPS means that there are not enough safety nets.

There is, I believe, compelling reasons to further dissect out-of-pocket spending versus the temporal profile of illness (clinical factors), and factor in what we already know about health-seeking behaviors (sociocultural factors). Let me lay down the foundational statements to explain what I mean:

(1) In the semantics of health, "Sakit" being the term for both disease and pain can suggest that pain may be essential in our folk conception of disease. This could explain in part why consults are delayed in illnesses that are initially painless such as tumors and the like. There is also the the concept of "Malayo sa bituka" (Far from the guts) which is another justification to delay consult

(2) If we speak of health as a 'business', our health care system is not a monopoly. There are alternative systems of health care which, playing by the laws of supply and demand, have an advantage by offering cheaper solutions and better, 'friendlier' services. These are the traditional healers who may be the arbiters of both medical management and health spending of the initial phase in the temporal profile of an illness.

(3) Strong family ties in the Philippines could lead to recruitment of more funds once the threshold has been reached where illness is considered grave, i.e. "Malma na" or "Malala na". The patient who initially had no money for a consult now has funds for a CT scan and an MRI, because the relatives from the States have remitted and a hectare of farmland has been mortgaged.

These three indicate that out-of-pocket spending may not be getting allocated according to temporal need (as defined by the clinician). There may even be instances when a patient could actually afford treatment, but it was not distributed appropriately per unit time. Indeed, a typical breast cancer patient in the Philippines may be spending the same amount of P1,500,000 as compared with a patient in Thailand (one of the better performing countries as per Dr. Banzon) but the outcomes may vary profoundly.

Why? Because a substantial portion of the Filipino patient's P1,500,000 was spent on the latter course of the illness: this was the time when she was willing to pay, this was the time when the "Malala na" threshold and thus the health insurance policy of every Filipino - strong family ties - is activated. This may also be the time when the patient begins to avail of hospital services having found no benefit from traditional healers and herbal medications. The opportunity cost of these alternative therapies too would weigh heavily in this discussion.

It will be interesting if we can generate plots that chart not only expenses per illness, but to plot expenses also against the the temporal profile of an illness, from the perception of illness to diagnosis to outcome (successfully treated, died, etc.). How much does a breast cancer patient spend in the Philippines? This question can be further expanded into "How much does a breast cancer patient in the Philippines spend throughout the course of her illness?" A good graph would show a gradual increase in spending but what I would expect to see is an initial under-allocation (clinically this will manifest as "lost to follow up" or "poorly compliant to medications") and then, towards the end, an over-allocation (and sometimes futile allocation) of funds. Doctors will end up hearing "Doc, gawin nyo ang lahat!" - a blank, desperate check for doctors to do everything. This could be an attempt to compensate for a perceived neglect on the part of the relatives, or simply a reflection of how serious the disease has become as a result of the above-described heatlh-seeking behaviors.

What will be the implication of these findings, if confirmed and quantified? To a clinician, this would simply mean the need for more patient education. But to a health economist, these temporal profiles can actually quantify opportunity cost and localize the particular weaknesses and points of improvement. Moreover, although OOPS is seen as negative indicator with respect to universal health care, it must be recognized for what it is worth: a resource that can be optimized if it is spent when it is of maximal benefit. Policies can then focus on prevention of futile spending, emphasis on preventive care, combating opportunity-grabbing alternative therapies, and a more aggressive appeal for patients to comply to initial management.

Properly managed out-of-pocket spending may also ease public spending, enabling its allocation to more pressing needs. The dynamics of private and public spending continue to be in a state of flux but in the meantime, we can micromanage both components to make it optimal. For instance, knowledge that the insurance policy of "strong family ties" is activated only with the pronouncement of 'serious illness' may be used by the physician as an ally in aggressively pursuing surgery in a Stage II cancer, where it could still be of maximal benefit. The economist can likewise use this cultural trait by allocating more (at least initially) in primary and secondary prevention where we have identified that there is an underallocation of private spending, but where a great need for financing lies.

I drew from a cultural perspective to support my points, but it can also work the other way. Analyzing where and when out-of-pocket spending goes can also help enlighten us more about the way people deal with illness. Indeed, health-spending behaviors (essentially OOPS, rephrased) may well be an excellent reflection of health-seeking behaviors can be an important focus on inter-disciplinary studies in the future. 

This is just one point where culture weighs in on the continued discussion on health financing. In a future article, I would also like to look at how a cultural perspective can help explain some of the problems that PhilHealth is facing with regards to universal coverage.

Insights from India: Health care, fifty years hence

Various Ayurvedic medicines are fast becoming "commodified" in India, underscoring a medical pluralism
that continues to evolve. (Sept. 2012)

by Gideon Lasco

LEH, JAMMU AND KASHMIR - In another essay, I reflected on how Ayurveda functions here in India. With this as a sort of background, how we can now prognosticate the health care systems in the Philippines in the coming decades?

India shows us two of the main phenomena that I think will play a major role in shaping the health care in the future. The first is medicalization, and the second is medical pluralism. Later, after explaining these two different but interactive concepts, I will speak of the means and trends by which these phenomenon will take off.

Medicalization is, simply put, the ever-increasing influence of medicine in the performance and sanction of society and our everyday lives. Foucault, in his Birth of the Clinic, traces the rise of biomedicine, and this theme of medicalization was articulated n Medical Nemesis, a book which warned that biomedicine has actually given rise of diseases – a process its author, Ivan Illitch, refers to as iatrogenesis. He saw medicalization as a dire phenomenon that would unfold towards greater detriment to people.

Theorizing in the Western world, Illitch did not see the manifold consequences of medicalization in a society where Western medicine does not have a monopoly in health care. For one, what we see in India is the utilization of medicalization as a tool towards the acquisition of legitimacy, as in the case of Ayurveda and even Siddha and Unani. Moreover, he did not anticipate the ways in which technology will liberate people from being subjects of biomedicine – for instance, through the proliferation of information in the Internet, the ubiquity of drugs that people themselves use. Finally, critiques of medicalization lose the potency of their arguments in a society where various, divergent, and at times complementary systems of health care exist, a state that Nguyen and others term medical pluralism.

These two trends are concepts by which we can plot the course of the future.

Medicalization remains a powerful and relevant idea in our contemporary society, and can be used as a heuristic device to describe how biomedicine has profoundly affected our culture. Without going through the extent of medicalization, we can just cite one example to make our case: the medicalization of childbirth.

In the past decade, the WHO declared that childbirth must be done in the hospital or the clinic, not at the home. The shift of the locus of birth from its traditional place is both significant and symbolic, it indicates not only the uprooting of previously-held practices, but also the impeachment of previous, culturally-designated bearers of knowledge on pregnancy, childbirth, and child-rearing. In my Tagalog-language health website, one of the most popular topics relate to pregnancy. “How to know if you're pregnant?” is one of the most viewed articles, and even “trivial” stuff like “Is it safe to drink cough syrups when you're pregnant?” come up on a daily basis. These are the questions that people ask – pointing to an area which our health care system has not provided for: the explanatory utlity of medicine in everyday choices and situations.

Thus the notion of medicalization is related to cultural upheavals that take place in its aftermath. The medicalization of knowledge, which we hinted at, means that the proportion of health care information available to laypersons has decreased. In traditional medicine, going through normal processes of life, such as birth and death, were handed down as part of folk knowledge, from generation to generation. Traditional healers were at hand to faciliatate these life stages, but everyone was familiar with what is being done. In biomedical childbirth, as in many medical procedures, the woman (who becomes a “patient”) has little idea of what is going on.

Ultimately, this informal asymmetry paves the way for other health care providers, formal or informal; virtual or real, to enter the health landscape. Ironically, medicalization leads to medical pluralism. And it also leads to a clogged healthcare system, with overconsultation, overmedication: symptoms of overdependence in biomedicine.

Medical pluralism does not always lead to the best outcomes. In some cases, these providers prove unreliable, or worse, deceitful. Self-care, in the absence of an environment which provide (or foster) knowledge among the lay, can also lead to destructive practices like self-medication.

In the above paragraphs, I illustrated how medicalization has far-reaching consequences in society. It is not difficult to see how this will continue in the future, with technologies that challenge and redefine our notions of health, wellness, and beauty.

Genetics is one of these technologies. By claiming to see the future of the human body, it transposes “diseases of the future” as “illnesses of the present”, and this will play into cultural beliefs and practices as well. The emphasis on biological (i.e. genetic) determinism will challenge perceptions of health and wellness, and shape expectations of children, especially when these kind of determinism begins to pervade social, intellectual, and emotional development.

In India, technologies that allow couples to determine the sex of the fetus at several weeks' age of gestation, has led to abortions of females. This has led Nobel Prize laureate Amartya Sen in 1989 to decry the demise of the “missing women” that should have been born in India.  Again, it will be interesting how foreknowledge of traits will influence child-rearing practices, and what impact it will have on children, marriage, and family life. Perhaps the long-held notions of “pinaglihi” will give way to the notion of “genes” and “physical identities” will be expanded to mean not just phenotype, but also genotype.

For instance, many Chinese families are known to inspect their child's future wife or husband and screen them for genetic “defects”. A suitable match can be determined not just by congruence in personality, but also in genetics.

On the other hand, while novel medical technologies will expand the diagnostic capabilities of biomedicine almost to the level of prophecy (i.e. “Someday you will have breast cancer”), the therapeutic capabilities will also be increased. Genetics, in the long run, not only has the capability to identify future diseases; it can also eliminate them. Yet these technologies will be, at least initially, available only to those who can afford it. As the latest of numerous example, the recent craze of stem cell therapies among the uber rich

Moreover, what needs to be treated – i.e. what should be considered as a disease – will continually be expanded. “Physical defects” can now be managed by cosmetic surgery and dermatology; to look  “beautiful” is to look normal, even though this so-called “beauty” is a social, and oftentimes a commercial construct. When Dr. Vicky Belo and her crew invented the term “Belo-fied” as a desirable process of “beautification”, they are articulating both the reality of the process and contrived nature of it.

Indeed, technology is driven not just by pathologic or physiologic need, but by economics, and it is likely that these technologies of body enhancement will continue. As an indication of this, the Olympic Games are chronically marred by doping scandals. The other day, The Times of India ran a story about Lance Armstrong, whose spectacular record in the Tour de France has been tarnished, and will perhaps be retrospectively stripped off, as a result of  “more than a thousand pages of evidence” of systematic doping using EPO, steroids, and blood transfusions.

Perhaps, ultimately, humanity has to accept that body enhancement is not being artificial, but being human. But this acceptance will come at a high cost. For one, there are fears that these body enhancements will, like the firstfruits of genetic engineering, create a divide between the rich and the poor: Homo technologius and Homo sapiens.

Yet while these inequities would be magnified by further technology, they are seen even today, in procedures that are taken for granted in the West, but remain prohibitively expensive in nations like the Philippines. According to Dr. Alberto Romualdez, a former health secretary:

Every year, 8000 Filipino suffering from chronic kidney diseases will need renal transplantation. However, due to prohibitive cost of the procedure, only 500 transplants are done, virtually all of them on upper-class patients.

Technology, indeed, can be a driver of health inequity. However, whenever there is a need that is not met, any of the participants in the pluralism of medical systems can come in, especially if it offers the same therapeutic effect for a much cheaper cost.

Technology, however, does not only make aspects of health care exclusive to people who can afford it; in some ways, it also opens up health care to a greater segment of society. In the case of the Internet, for instance, it has liberalized knowledge, opening up technical and non-technical information to the general public. The challenge now is not the ability to store information, but the ability to interpret it.  Increasingly, patients will use online information to validate their doctors' diagnosis and treatment; or else, to self-medicate. In Kalusugan.PH, a website I created – the only health website in the Tagalog language, people's questions reflect their search for information and reassurance, but at the same time, the need for interpretation. At times, the simple “Which doctor to consult?” is an important question; the Internet will not oust the physician; but it will lead to a renegotiation of the doctor-patient relationship.

The Internet is significant not only for providing knowledge, but also by creating new communities in cyberspace. In health, this has led (and will continue to lead) to patients and their families, suffering from a similar disease, to forming forums, websites, and interactive pages in the Internet where they can find common cause, and where they can exchange their experiences. With the global scope of the Internet, this sort of community-building acquires a transnational nature, and previously scattered groups, such as people suffering from beta-thalassemia, can gain political power through this coalescence.

Globalization is another important driver, not only as a vehicle to proliferate technology, but also as a means to introduce various ideas on health, including health care systems. These global ways of healing do not only come to Filipinos; we also apprehend them in their native sites through our Overseas Filipino Worker (OFW) population. Conversely, we export our own beliefs with our OFW population; it will not be surprising to find a manghihilot in Hong Kong. However, in the same way that it has been criticized for favoring multinational companies over small businesses, globalization favors organized health systems, not fragmented ones like our indigenous system of healing. It is Ayurveda and Chinese Medicine that have a big chance of making inroads in other countries' health system. On the other hand, new forms of media would still allow voices from individuals: a best-selling author can easily change health habits overnight: we saw this in the faddist South Beach and Atkins diets in the 1990s.

Medical pluralism allows the comparison of various health care systems, and the public appraisal of  which among them work for particular conditions. This, in the long run, can pave the way for a synthesis of medicine that draws from the best of each of the systems. Ultimately, features of a particular form of medicine may be integrated into the dominant system of medicine, beyond recognition of its original form or source.

What is the implication of these trends for the health care system in the Philippines? Unlike India, we do not have a codified system of traditional medicine. Thus, the geography of health care systems consists of just one supercontinent, that of biomedicine, surrounded by islands of indigenous forms of healing. On the other hand, it can be argued that although traditional medicine is disorganized and therefore minute in scope, this is only true insofar as professional practice is concerned; its concepts continue to pervade the lay population, and its practiced by folk healers; it thus inevitably intersects with biomedical practice at the level of individual patients, families, and communities; it comprises the corpus of practice and knowledge through which biomedical prescriptions are filtered and interpreted. The physician's advice to buy an inhaler for asthma, thus, can be modified to include lagundi leaves, or plasters; its dosage and frequency can likewise be modified. Health systems are never just top-down regimes; “patients” continually challenge and reinterpret prescriptions according to their own knowledge and practices. The works of Tan, Nicther, and Hardon in the 1990s are demonstrative of how Filipinos do this – often in creative ways. In interviewing traditional healers around the Phlippines, I have personally witnessed how antibiotics such as Penicillin are eviscerated from their capsules, and are smeared on wounds as topical treatment – a form of therapy that Alexander Fleming would never have imagined.

Medical pluralism in the Philippines, thus, takes a different form, one in which a dominant health system has no clear rival.  This does not preclude the introduction of other health systems: acupuncture is making inroads in the Philippines, particularly for pain relief.  A growing number of physicians are taking up pranic healing and other healing modalities. Moreover, whenever changes in the health landscape take place – such as the emergence of new illnesses – the curative and explanatory power of the dominant health system may be challenged by novel forms of healing that arise from the cognitive milleu made possible by the “islands” of indigenous medicine. During the dengue outbreaks in 2010 and 2011, healers using tawa-tawa (Euphorbia hirta) as “cure” for dengue became popular, and enough people believed them to a point that they could charge several thousands for each case. This phenomenon can easily be reproduced in the future, following resurgent and emergent health threats. Curiously, the availability of biomedical knowledge in the Internet can easily be used by present and future healers to enhance their syncretism to one that is more “educated”, more “medical”, and therefore more credible. This is no different from the strategy being used by Ayurvedic schools here in India that we mentioned in the first essay: the utilization of elements of the dominant health system to validate others.

It is not only healers that expropriate the validity of biomedical knowledge to boost their credibility; commercial interests also do so, in fact, they do the same thing for indigenous medicine, creating and marketing products which, like the Ayurveda in India, have a “double validity”, this time coming from indigenous medicine (i.e. the use of herbs) and biomedicine (i.e. the presence of enzymes, vitamins, antioxidants, and other 'high-sounding substances'). It must be recognized that in a state of pluralism, “individual medicine” - self-care and self-medication – is an important player – and we can expect this to grow in importance in the coming decades. In the same way that indigenous forms of healing gain prominence in illnesses where biomedicine is having problems, such as difficulty in accessing it, or difficulting in effecting cures, commercial products also succeed where biomedicine does not offer a clear cure or definitive treatment. Today, popular products are those that claim to cure cancer, “aging”, reproductive and sexual health concerns such as virility and potency, as well as beauty needs like skin whitening. Sellers of these products will also make use of the Internet, as well as traditional media, to bolster their claims. Again, the important thing to observe here is that in the future, there will be a co-evolution of new “technologies of the self” and technologies that convey and communicate these technologies.

Biomedicine, thus, will be under continuous pressure to reaffirm its dominance by demonstrating its efficacy in people's health needs. Because it has a built-in mechanism to validate its own claims, as well as an organized membership that works to perpetuate its hegemony (i.e. medical societies), it is likely to remain the dominant health system. Nonetheless, a state of medical pluralism will continue to challenge it, particularly whenever there is economic impetus to do so, or there is a void in biomedicine which opens up the possibility of a competitor. In India, exponents of Ayurveda are keenly marketing it for chronic illnesses, preventive and holistic care, and particularly diseases like psoriasis and rheumatoid arthritis. What these aspects of health care have in common is that they are among the weaknesses in biomedicine.

Medicalization, on the other hand, will continue to put biomedicine in a position of profound influence in society, its weaknesses notwithstanding. Illitch reasoned that this emergence coincides with the collapse of other institutions such as the religion and the church. The best illustration for this is the field of psychiatry. While still relatively new in the Philippines, it is a growing field, and can be held responsible for the medicalization of various forms of behavior. Depression, anxiety, hyperactivity among children, and addiction to various substances, are also under the domain of psychiatry, and the medicalization of these novel “illnesses” will shape perceptions of them, and these will have implications even in our legal system. Perhaps as the influence of organized religion in the Philippines wanes, we can expect more of Psychiatry.  There is so much that we do not understand yet of mental illnesses, particularly in cultures apart from that in which psychiatric concepts were developed, including the Philippines. Medicalization of the mind and of behaviors, which is the project of Psychiatry, is worth observing in the coming decades. What threads in our social fabric need to be loosened, in order to trigger a rise of these mental illnesses? What are the forces at play when a community begins to abandon belief in kulam, and embrace instead the notion of mental illnesses determined by biology, genetics, and the environment?  It ought to be considered a 'moment' in our cultural history when people begin to replace notions of 'deviance as sin' and 'deviance as crime' for 'deviance as mental illness' – to paraphrase Thomas Szasz, a psychiatrist who has criticized the far-reaching powers and scope that Psychiatry has assumed for itself.

Medicine derives much of its curative power from technologies, and radical technologies can alter the health landscape in unpredictable ways; these in turn influence society in manifold ways.

Medicalization can also be spurred by novel diseases, which, by posing a threat of society-at-large, provokes a reliance of that society to medicine. The rise of HIV/AIDS, Nguyen writes, “remedicalized” society, giving rise to a 'therapeutic state' whose surveillance function necessitated the testing of people, and their classification either was 'positive' or 'negative', in itself creating identities that Nguyen terms “therapeutic citizenship”. HIV/AIDS likewise served as a metaphor for the danger of sex, and, at least in the West, it is said to have a put a halt to the libertine sexual lifestyle of cities like San Francisco and New York. In mountaineering circles, there is a joke which goes: “In the 1960s, sex was safe and climbing was dangerous. Nowadays, climbing is safe and sex is dangerous.” This statement reflects the changes in the perception of sex which was brought about in large part by notions of medical harm. And these perceptions affect us in concrete terms, through strict medical tests performed on applicants for work, and the inevitable moralizations that HIV/AIDS evoke. When Paul Farmer denounced the identification of Haitians as a high-risk group for the then-poorly understood HIV/AIDS, he is reminding us of the grave potential for stigmatization of groups that are 'high-risk' for particular illnesses, particularly infectious ones. In 2009, the report that call center agents had a high prevalence of HIV/AIDS caused a nationwide furor. This is just one of the consequences of illness in a globalized, “media-fied” world. It is speculative whether such diseases will emerge in the coming decades. The WHO predicts that a pandemic may happen anytime, and globalization will facilitate this. The world is at once a safer and a more dangerous place.

Medicalization is assured by an endless race between pathogens and technologies, and exacerbated by an ever-expanding taxonomy of diseases, which now range from the organic to the functional to the speculative (genetics) and the contrived (i.e. aging, “ugliness”, “short stature”).

At the end of a lengthy discussion on medical pluralism and medicalization, perhaps the reader will have the sense of uncertainty about the future, and this is exactly the case: While we can speculate on things to come, we can by no means make accurate forecasts. In the same way that HIV/AIDS caught the entire world off-guard, there may be future diseases that would transform the health landscape in a radical way. On the other hand, there are also technologies that might accomplish the same thing.

However, what we can do with a greater degree of accuracy is to anticipate how people will react to these changes. We can approach the future of health care at according to the various lenses of medical anthropology, and here is where I will conclude my piece:

At the level of phenomenology, these diseases and technologies will be received and approached by people according to their personal experiences and circumstances. They will develop their own explanatory models of not only illnesses, but therapies and technologies, and they will also develop their own practices that may be dystonic or syntonic to that which the medical establishment wish to. Technological tools, such as the Internet, will provide them with more access to knowledge as well as a wider social universe in which these practices are introduced, circulated, and reinforced. The initial project of anthropology was to come up with ethnographies that capture and preserve a moment in a particular culture, hence it clings to what it calls an “ethnographic present”. The modern-day function of medical anthropology, however, is to document change in practices and knowledge and relate it to these aforementioned dynamics of health care systems, technologies, and diseases. The locus of ethnographies will increasingly shift towards this new “social universes” created by the Internet and future technologies.

At the level of medical ecology, which looks at interactions between individuals and communities, society and the environment, populations and pathogens, we would see how transformations in one member of the ecosystem could lead to changes in others; and with the Internet and globalization – major trends we identified – new ecosystems will be created, which will feed back into old ones. Even “non-health” trends such as global warming,will have far reaching health implications, altering not only the geography of disease, but also changes in human practices and perceptions. The utility of medical ecology as an approach is its ability to look into these relationships.

Finally, at the macro-level, a political economy perspective must take a critical look at how technology is driven by various interests, and how a globalized world is creating wider, more potent forms of hegemony. The conspiracy theory of a global pharmaceutical company manufacturing a disease then selling a “cure” for it, while extreme, is nonetheless a good metaphor of what the confluence of globalized “political forms” has enabled.

Here in the Ladakh province in Jammu and Kashmir, where Tibetan Buddhist stupas point to the sky, and where the barren, mountainous landscape has changed little since the time of Alexander the Great, it is easy to think that the future has not yet arrived. Yet, I am able to access the Internet here, albeit intermittently, and in the world news today is the report of a new, “SARS-like virus” from Saudi Arabia. The two cases -  one in the United Kingdom and the other in the Middle East – are both traceable in Saudi Arabia. Although no new cases have been reported, fears of global pandemi are juxtaposed with calls for reassurance from WHO and other health agencies. The discourse unfolds.

The future will come sooner than expected.

Leh, Jammu and Kashmir, India
September 29-30, 2012

Notes on Ayurveda in Nepal and India

Observing an ayurveda session in New Delhi, India (Sept. 2012)

by Gideon Lasco, MD

LEH, JAMMU AND KASHMIR - The first step in anthropology is a step back. A dinner conversation becomes a form of ethnographic data-gathering when you cease participating in it solely, but also begin to observe. Sometimes, the problem in “stepping back” is being unable to step in again, and anthropologists are often observers of their own lives, more than those of others. On the other hand, whenever I am traveling, I find the anthropologist's perspective very useful. I am reminded of a friend of mine who is a hiker and a birdwatcher; she says that since the mountains are full of birds, she has no problems in joining my hiking trips; she can also do “incidental birdwatching”, as long as I don't mind her occasional stops.

Perhaps, traveling is much an enabler of anthropology as mountains are of birdwatching, only that I should also slow down a bit. Then, incidental anthropology can contribute as much to my understanding as a deliberate one.

This is how it has been in our field trip, where my classmates and I went to New Delhi to learn about Ayurveda. There were only three days scheduled for the actual “exposure” to Ayurveda, which consisted of meeting with private and public institutions of Ayurvedic medicine. However, I spent three weeks in India and Nepal, and my encounters with Indians of all walks of life broadened my perspective about Ayurveda.

The first South Asian city I visited was Kathmandu. I arranged for a meeting with the Fiipino community there, which mainly consisted of wives of Nepalese men. After exchanging pleasantries and receiving the plea for daing (dried fish) which they sorely miss, I had the chance to ask them about life in Hindi culture. They introduced some realities to me about Hindu culture, particularly the caste system. As daughters-in-law, their sorry role is to cook the food for the entire clan, because servants, being of a different caste, are forbidden to prepare or cook their masters' food. t is also very interesting how the women bring their own beliefs with them. In advising us to visit the Hindi temple called Pashupatinaph where cremations are routinely done, she warned us not to look at the priests, which had a powerful gaze that is sure to cause usog.

What do they do when a member of the family gets sick? Just like in the Philippines, Western medicine is at hand. When I asked about Ayurveda, one of them responded:

Yung Ayurveda, para 'yang kung sa atin, yung mga albularyo, pero sa kanila, big-time. May sarili silang ospital...pero meron din namang mga dyan lang sa tabi-tabi. Effective din daw pero kami, dun kami nagpapatingin sa doktor na parang sa atin lang... (Ayurveda, it's like what we have – the traditional healers – but to them, it's 'big time'. They have their own hospital, though there are also those that you can just find in the corner. They say it's effective but for us, we jus consult the regular doctor, just like in our [country])

Another adds:

Ayurveda kung tawagin, para yun sa mga sakit na hindi mapagaling ng mga doktor, yung mga malala na. Mas maganda daw ang pakiramdam. (What they call Ayerveda...it's for those who have illnesses that couldn't be treated by doctors, those which are already severe. They say that the feeling is good.) 

After our conversation, I tried to look at how the caste system has affected Ayurveda, but I was not able to get specifics. Many writers have written about the caste system as a “historical inequity” but apparently, in Ayurveda this was never a problem. Perhaps this is because this particular health system has co-evolved with Hindu society throughout the centuries.

In Kathmandu, there are several big hospitals, including a heart center, but you could also see Ayurvedic hospitals, clinics, and “chemists”, not to mention occasional advertisements for Tibetean medicine. It would become a foreshadowing of what I would see in India: medical pluralism.

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ARRIVING IN New Delhi, I saw many more of the 'chemists'. Some sell exclusively  Western pharmaceuticals – at much cheaper prices (I bought two rounds of Azithromycin treatment, at P10/tablet). Other chemists sold both Western and Ayurvedic products, while still others focused primarily on Ayurveda.

After Taj Mahal and the inevitable gems and carpets that were peddled to us, we reached the highlight of our trip: visits to private and public institutions of Ayurveda.

On our first day, we went to a private Ayurvedic hospital – the Delhi branch of a chain of hospitals that from Kottakal, in Kerala. Our host was a scion of the Varier faimily, whose patriarch P. S. Varier established the first Ayurvedic hospital in 1902.

His office was just like any other MD in the Philippines: Framed diplomas, bookshelves full of medical textbooks, elegant interior design. He also wore a white coat, and  a stethoscope hung prominently on a rack beside his table. Perhaps the only thing that would not be found on a Filipino physician's office was a portrait of Dhavantari, the “god of Ayurveda”.

The way he talked was very physician-like: affable, congenial, and knowledgeable. He deftly answered the question of Dr. Gueco, a nephrologist, about side effects, invoking pharmacologic concepts of lethal dose and therapeutic index. Hand-in-hand with his knowledge of Western medicine was his eloquent exposition of Ayurveda, from its history, its eight specialties, and so on.

His manner and conduct; his personality, and his office – very Western, and yet, avowedly Ayurvedic, symbolizes and shows how Ayurvedic medicine try to achieve a “double legitimacy” of their heath care system but applying (or borrowing) scientific (i.e. biomedical) methods of validation. My classmates (and myself) were visibly impressed by this kind of proficiency and fluency in the language of medicine.


The next day, our meeting with the AYUSH Council (Ayurveda, Yoga & Naturopathy, Unani, Siddha, and Homeopathy Council) affirms what I observed in the private hospital: there is a conscious effort to present Ayurveda as professionalized and modern (i.e. Western). There is no mention of the Hindu religion, nor of the mantras that are required to make the therapy a success – a requisite act in traditional Ayurvedic practice. Instead, 14 successful randomized clinical trials on medicinal plants were presented, together with the curriculum for Ayurvedic medicine that is identical to that of Western medicine, including lessons in anatomy and physiology (side by side with “Ayurvedic literature”).

We see, thus, that the medical pluralism of India, elements that fortify the position of the dominant health system (i.e. biomedicine) are borrowed by the other health systems to strengthen their own validity and credibility. The less flattering (at least to the eyes of observers) aspects of Ayurveda, like the prayers, and the side effects of therapy using metals, were glossed over.

Moreover, there is an awareness that whatever Ayurveda is, it must fit within the larger picture of health care in India and elsewhere. Instead of being packaged as a health system that can take care of everything, its exponents highlight its strengths in focused areas, such as chronic illnesses, specifically psoriasis and rheumatism, as well as preventive care, and palliative care. The AYUSH people are very careful not to make claims of Ayurveda as superior to other healing systems. It is as if there is an unspoken armistice of Western medicine, that it will be tolerated as long as long it does not encroach on Western medicine itself:

Patients are free to choose what treatment they want. If they choose Ayurveda, okay. If they choose Western medicine, it's okay also. We do not impose Ayurved. It's up to them. And if we think that Western medicine is better, for instance for emergencies, we also tell them.

Another often-highlighted aspect of Ayurveda is  its “safety” i.e. “no side effects” and “it is all natural” is an attribute of Ayurveda that is oft-mentioned, by laypersons and professionals alike.

In Ladakh, in the Indian province of Jammu and Kashmir, I met several Indians,  from various cities, and I had the chance to  ask them what they think about Ayurveda. An Indian couple, from Mumbai, spoke highly of it. Another couple, from Assam, had a son who was a medical student, and said that they preferred Western medicine, citing its proven safety. But even they acknowledge that Ayurveda has its strengths, like “those hopeless cases”. Moreover, they have personal experiences of illnesses. As an affluent man from Delhi told me:

For our chidren's coughs and colds, sometimes we use Ayurvedic medicines, sometimes, we buy from the chemist. The irony is, I suspect that even we don't give them anything, they'll still get well! 

What emerges from our India experience is the existence of parallel, but co-adaptive professional sectors of medicine, folk and popular sectors that employ elements of both, and patients taking their pick from various “choices”, using their own experiences as guide. “Doctor shopping” becomes more interesting in a world where various developed and respectable health care systems exist; it becomes “health care system shopping” instead.

Observing the reactions of my classmates, and reflecting on my own, two things impressed us: one, the exotic-ness, and its Western-ness of it. Perhaps, in the future of Indian health care, Ayurveda will be indistinguishable from Western medicine, Ayurveda being so Westernized, and Western medicine adopting some of the best practices of Ayurveda.

As for religion, Western medicine was once closely linked with Christianity, but it has since distanced itself from it. I would venture to speculate that as Ayurveda becomes more “scientific”, and as it draws more legitimacy from clinical studies and experimental methods, it, too, will do away with its “excess baggage of Hinduism” whenever convenient; even as Hinduist Ayurveda will continue to appeal to its traditional Indian clientele.

Based on what I have seen and learned in India, then, the success of Ayurveda can be explained in terms of the following characteristics of it, all of which contribute to the claims of legitimacy and validity of Ayurveda:

1. Longevity – The fact that Ayurveda has been around for so long is used to support its claim as a legitimate health care system. It is true that Ayurveda has its origins from the first millennium before Christ, and has been in continuous use since then. However, the idea of an unchanging, timeless system of medicine needs to be challenged. Islamic influence in India, which brought the unani system of medicine, has also influenced Ayurveda, beginning in the 1100s and reaching its zenith during the Mughal empire (1556-1758). Moreover, following the introduction of Western medicine in the 19th century, Ayurveda has gone through a series of adaptations that continue to the present, absorbing the best of Western medicine and developing its own strengths.

2. Claims to divinity – Closely related to longevity is claims to divinity that Ayurveda espouses. Dhavantari, the mythical founder of Ayurveda, is also known as the physician to the gods. The images of Dhavantari in clinics and wards show that this mystical connection is still honored; a large statue of the god adorns the lobby of AYUSH compound in New Delhi. I had the impression that this is something that was not highlighted to us by the people we met, probably since we were outsiders to Hindu culture. But its presence is evident in many places and instances. The revered founder of the Arya Vaidya Sala private institution, in his official biography, is acclaimed not only for his pioneering work in Ayurveda, but there is a short paragraph at the end telling of his commitment to a Hindu dance troupe.

The complexity of India makes it difficult to predict whether the relationship of Ayurveda with Hinduism will continue to be embraced by its exponents in the future. With Ayurveda increasingly validated by science, perhaps there would a wider latitude for it to become more “secularized”. 

On the other hand, by over-embracing the biomedical divorce of science and religion, Ayurveda might undermine the very reason for its appeal in the first place: its holistic approach to health, seeing its spiritual and emotional dimension alongside the physical. Given this, I would wager that Dhavantari's statue in the AYUSH building will still be there when the next batches of medical anthropology students go on their Indian field trip

3. Efficacy – Efficacy is crucial to any medical system, and this can be measured either as perceived by the people, or by an external mechanism for validation, such as the scientific method. Importantly, the latter method feeds into people's perceptions as well, making it very influential, especially in cultures where “blind faith in science” - as Hawking's philosophical perambulations have been described - is prevalent. In my interviews with people, most of them say that Ayurveda works for them, and they cited their personal experiences.

The scientific case for the efficacy of Ayurveda is more complicated, and perhaps this is a project that will take decades to resolve. A PubMed search would reveal mixed results of conclusive and inconclusive studies, although there is a growing consensus that Ayurveda has benefit in particular illnesses, such as rheumatoid arthritis, chronic illnesses, and palliative care. Moreover, herbs and therapies such as yoga and meditation that have long been part of Ayurvedic therapeutics are increasingly validated by Western studies.

The open-ness of Ayurvedic institutions to having its therapies examined under the microscope of biomedicine will ultimately be for its good, allowing it to have both the “double legitimacy” of sacred texts and scientific research, and the reflexivity that will allow self-improvement.

4. Safety –  Doctors and patients of Ayurveda agree that one of the remarkable strengths of Ayurveda is the fact that it has “no side effects”. This reasoning comes from the fact that since Ayurveda draws its remedies mainly from plants and natural products, there is none of the “harmful chemicals” that go with Western pharmaceuticals. This discourse is not unique to India; we see this being played across various cultures where Western medicine and traditional systems of healing are compared and contrasted. In the Philippines, we see this in the “cough remedy wars” being waged between manufacturers of lagundi and manufacturers of conventional cough syrups.

Many critics of Ayurveda have pointed out that its use of heavy metals as therapy is problematic, and the toxicity as a result of such therapies is becoming a  growing albeit poorly-documented problem that is spreading globally as Ayurveda becomes global. As a 2008 report concludes:

A significant proportion of Ayurvedic medicines contain heavy metals and there are numerous reports of heavy metal, in particular lead, poisoning related to use of these products. In patients, both adults and children, presenting with unexplained anaemia, or unexplained gastrointestinal or neurological symptoms, heavy metal poisoning should be considered in the differential diagnosis.  

The doctors we interviewed counter that these side effects are no different from side effects from biomedicine: they are inevitable in the wider scale, but avoidable if proper techniques are followed.

This issue is hard to adjudicate, given the limited number of studies that deal with toxicity from Ayurvedic therapies, and the qualification of what constitutes “good Ayurvedic practice”. What is important to note, however, is the fact that Ayurveda's perceived safety contributes to its popularity.

5. Holism – The approach of Ayurveda to health is no support the body, strengthen the immune system; not to kill the germs. The massages are said to be “very relaxing” and “very comforting”. Perhaps, the function of Ayurveda as a provider of comfort is no different from the hilot sa panganganak, who provides much comfort (ginhawa) to the women after childbirth, something that Western medicine does not have.

6. Adaptability – This is not an external feature of Ayurveda, but as we mentioned earlier, it is a striking asset without which, in all likelihood, Ayurveda would not have survived. Perhaps, this feature is the one that enabled it to achieve longevity and receive validity from both the scientific and the sacred.

In my interviews with traditional healers in the Philippines, I was also able to observe much adaptation, with some healers using cellphones, X-rays, and other technologies; while others take on emergent diseases using their own techniques, and in this way, cancer, dengue fever, and HIV/AIDS falls under the scope of their practice. What is remarkable in India, however, that  this adaptation is done in an organized, not individual scale.

The degree program for Ayurvedic medicine, however, is styled “Bachelor of Ayurveda, Medicine, and Surgery”. Established in 1940, its holders are entitled to practice not just Ayurveda, but also modern medicine. This indicates that early on, the degree of integration has been fairly high in India, which can explain why Ayurveda has attained a degree of sophistication that cannot be said of other traditional medical systems around the world, with the exception of Chinese and Korean medicine, as well as, to a certain extent, homeopathy.

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In this short piece, I related my experiences and insights on Ayurveda in India. But what of yoga, siddha, unani, and homeopathy? We did not have time to explore these other systems of healing, but surely, they add to the richness and diversity of health care in India. Scratching the surface of it, I am no different from Alexander the Great, who was, as an important part of the Ayurvedic history narrative goes, “very much impressed”.

India
September 2012