[Second Opinion] The politics of compromise

by Gideon Lasco
Philippine Daily Inquirer

It was a foregone conclusion that the rubber-stamp Congress would pass the death penalty bill despite its many flaws. Even so, it was still interesting to look at how individual members voted.
Of course, few expected the political dynasts and the trapos to go against Pantaleon Alvarez’s marching orders; you have to be an Arroyo or a Marcos to pull off a dissenting vote and maintain good ties with the Speaker and the President. But for the supposed mavericks in the House, there was an expectation that they would at least put up a brave resistance.

It was disappointing then that Geraldine Roman—“the first transgender woman in Congress”—voted for the death penalty bill. The expectation, after all, did not just come from the idea that her open-mindedness in gender issues would translate to open-mindedness in other matters, but also from her previous opposition to the death penalty: Just last year she was quoted as saying that “people who make mistakes in society” deserve a second chance.

Roman explained her vote by saying that her own convictions notwithstanding, 85 percent of her constituents wanted the death penalty, and that as their “representative,” she was duty-bound to follow them. “I am part of the world of politics, and politics is compromise,” she told law students in Ateneo. “As much as I would want to follow my conscience to vote against the death penalty, I have the interests of the constituents, of my constituents in Bataan, in mind.”

What did she mean when she said that “politics is compromise”?

Roman herself provided a clue in her talk: “What about my other advocacies? Should I have held on to a sinking ship and ran along with me and my constituents and my advocacies? Try and understand my situation.”

Perhaps her justification is merely a sophisticated way of admitting that she jumped ship as an act of political self-preservation. But at the same time, I also see that her attitude is shared by many of our country’s leaders, which is why we must try to focus on where this attitude is coming from—and leave her alone for the time being.

Let’s start off with a thought experiment. Say you’re a passionate supporter of a certain cause, like the construction of dedicated walkways and bike lanes in our major cities. Having no other channel to raise your ideas, you post about them on Facebook. To your pleasant surprise, it goes viral! Then, amazingly, a government official invites you to Malacañang so you can present your ideas to the president himself!

“Very good! I will sign an executive order right away,” the president says, much to your elation. Finally, your vision of walkable and bikeable cities is within reach! But he adds a caveat: “Of course, I expect you to stop criticizing the drug war.”

Now you happen to be a critic of the extrajudicial killings—but you also feel that you’re in a unique opportunity to advance your cause. What would you do? The battle here, as is often the case, is not between good and evil, but between two forms of good. For legislators and even Cabinet officials, the choice is between focusing on their initiatives at the cost of leaving the presidency alone in other matters—or criticizing the president at the expense of losing the positions with which they can pursue their initiatives. Faced with the same dilemma, what would you choose?

Most of our leaders today are choosing compromise.

To some extent, this form of pragmatism makes sense in a system where the president is all too powerful: If he were a smoker, he may never order a nationwide smoking ban, but maybe we can get him to sign a law imposing a “sin tax” on tobacco. If he hates shabu with a vengeance, he may never adopt a harm reduction approach to drugs, but maybe he can embrace the same approach to reproductive health: That should, the thinking goes, be good enough for now.

But if helping to legitimize an unjust measure—or indeed, an unjust regime—either by open support or convenient silence, is the price for your initiatives to be supported, is it worth paying? I hope our leaders realize that there’s a very thin line between complicity and compromise.

Originally published in the Philippine Daily Inquirer on March 23, 2017: http://opinion.inquirer.net/102670/the-politics-of-compromise

[Second Opinion] Why we need a second opinion

by Gideon Lasco
Philippine Daily Inquirer

When people find out that I’m a doctor, conversations often take a medical turn. Thus, I have come to know, from experience, that most people like to talk about their health and those of their significant others.

“My daughter nearly had an appendectomy,” a mother recounted to me recently. “We brought her to a clinic because of a stomachache, and after doing an ultrasound, the surgeon told us that she has appendicitis, and had to be confined as soon as possible for surgery! Of course, we believed him, and said that we will make preparations. But after we got home and she managed to poop, her stomachache subsided completely! Instead of going back to the hospital, we decided to consult another doctor, who said it was just a bad case of food poisoning!”

She concluded: “Imagine what could have happened if we followed the first doctor, and she got operated on! All for an upset stomach! That’s why I always go for a second opinion.”

To be fair to the first doctor, his recommendation for admission may have been a prudent course: While he might have made a diagnosis of appendicitis, he didn’t really propose an immediate appendectomy. Diagnosing patients is not an exact science; doctors need some time to make a definitive one. Even if a doctor makes a wrong diagnosis, I would still go back to them because they would have a better idea the next time around.

But the patient’s mother has reason, too, for some skepticism. Some studies show that up to 20 percent of all appendectomies are unnecessary—just as up to 15 percent of caesarean sections are actually unwarranted. When one’s life and health are at stake, surely we want to know as much as we can to make sure that the risks are worth taking.

***

In titling my column “Second Opinion,” I draw from my medical background to remind us that many of our society’s issues also need alternate ways of (re)thinking and (re)telling. All too often, dominant narratives go unchallenged, either because they are held by those in power, or because they have been held by our society for far too long.

The diagnosis of our country as a “narco-state,” the prescription of capital punishment, the prognosis of a disaster that can only be averted by authoritarian rule: All these require a second opinion—hence the enduring relevance of these editorial pages, and of responsible and fearless journalism.

But the need for different perspectives go beyond the vexing political issues of our time. The advent of late modernity and globalization’s uneven terrain has given rise to various technological, environmental, social, and ethical conundrums. Certain ideals of “development” and “progress” are taken for granted, leaving us with little or no time to reflect on their ramifications. Significantly, our country is faced with worsening inequities, which allow people living in Metro Manila to inhabit entirely different worlds: one of survival, another of decadence, and in between, a resignation to a never-ending commute.

But out of the multiplicity of issues at hand—from the existential to the everyday—the writer will always be pressed to choose which to highlight. In this, I bring in the tradition of social medicine, whose early exponent, Rudolf Virchow, once said that “doctors are the natural attorneys of the poor.” Is not malasakit (empathy) the logical and moral response to our intimacy with sakit (pain and suffering)? Our commitment indeed should not just be to art or truth, but also to social justice.

A second opinion, however, remains an opinion: It does not rule out the validity of the first, nor its own erroneousness. Moreover, like the cardiologist who sees a heart defect and the psychiatrist who sees a broken heart, it is entirely possible that we are looking at different parts of the same whole.

And so it is with the conversation I hope to join. From a monopoly of discourse, we should move not so much to dichotomies as to pluralities: a multitude of voices that can hopefully move us further in the ongoing work of understanding each other, making sense of our ever-changing culture, and finding our nation’s place in the world.

Note: Published on March 16, 2017, this is the inaugural piece in Gideon Lasco's weekly column in the Philippine Daily Inquirer entitled "Second Opinion" which comes out every Thursday: http://opinion.inquirer.net/102467/need-second-opinion

"Tumataba ka ngayon"; "Pumapayat ka ngayon": Why we greet each other with physical appearances

by Gideon Lasco

In the Philippines, family and friends sometimes greet each other by commenting on changes in their physical appearances. Common examples include:

“Tumataba ka ngayon ah!” (You’re getting fat nowadays!)
"Bakit parang nangangayayat ka?" (Why is it that you're becoming thinner?)
“Bagong gupit!” (New hair!)
“Blooming ka ngayon ah!” (You’re 'blooming' today!)

Many have wondered why physical appearances figure in Filipino greetings, and some have frowned upon - or even ridiuculed - this practice. But before we form a negative opinion about it, let us first examine what this form of greeting does in our everyday lives. In what follows, I offer my insights based on my personal experiences:

First, it establishes when people last saw each other. By using the body as a clock, people are able to date their previous encounters. Take note that the greeting is not “You’re fat”, but “you’re getting fat”; tumataba, not mataba. The progressive tense links past and present, and invites people to talk about what transpired in between.

I realized this when, in a previous reunion, one of my titas said I was getting fat, and another said I was getting thin. At first I thought that such contradictory comments are proof of the greetings’ perfunctory (and therefore meaningless) nature - people just say it because they feel compelled to say something. But it later dawned upon me that the two titas actually saw me in different times: one saw me after I arrived from the US (where I almost always gain weight thanks to my relatives), and the other saw me after my PhD in Europe (where I almost always lose weight due to the pricey food and my tight budget).

The fact that I had to explain my changed body by telling them where I traveled, and what transpired in those travels, made me realize that the body, by establishing previous encounters, serves as a starting point for further conversation.

Second, it communicates a concern for one another’s health and beauty, as when, instead of just asking “how are you today?”, a family member comments on your growing belly. Take note that in these greetings, people are not measured against other individuals, but against their own (previous) selves.

We can see this during high school and college reunions, where people tease their former classmates for having gained weight, fully expecting them to return the ‘compliment’. Can we not link these greetings, then, to a shared nostalgia of our former bodies?

Finally, it speaks of a different kind of openness in our culture. We always think of Filipinos as more reserved (“mahiyain”) in the way we express our feelings, compared to the more straightforward Westerners. But there are also aspects of our lives where we are more open. Filipino psychologists speak of our notion of “kapwa” as proof that our society has never seen the "self" and the "other" as fully distinct - and I think we should move towards "embodied" way of looking at this intersubjectivity.

***

As Christmas draws near, we will hear more and more of these greetings in parties and gatherings. Surely, one year of cross-fit will earn for a young man a “ang ganda na ng katawan ni Junior!” from his doting grandparents; the young woman who cuts her hair short will not go unnoticed. On the other hand, when I hear stories of people who suffer beneath their smiles, I also agree that in some contexts, this way of greeting has become offensive in a day and age when people have increasingly staked their identities and notions of self-worth in their physical appearances.

One way of dealing with this problematique is to reserve our appraisal in settings where people share the same level of intimacy: I don’t think it’s a good idea to comment about your teenage niece’s weight in front of her barkada. Another is to be sensitive for instances when it can be offensive: surely, someone who is struggling with weight not need be to be reminded of her obesity. In other words, we must learn to appraise not just other people’s physical appearances, but their feelings.

These concerns notwithstanding, I hope we can appreciate the good in our customs, and not always resort to self-disparagement. Our way of greeting, I submit, invokes an intersubjectivity that involves not just our social selves, but our physical bodies; a concern for each other’s health and beauty, and a desire to link the present and the past. In the Philippines, we greet each other by commenting on changes in physical appearance, and I think that's wonderful.

Los Banos
December 5, 2016

Cancer and the merchants of hope

“Sayang ang mga buhay.”

Thus was the lament of my colleague, a medical oncologist, who confided to me her frustration over cancer patients who seek alternative treatments: “They would come in the early stages, and we would advise surgery and other treatments. But instead, they would resort to unproven kinds of alternative medicine, from cabbage leaves to mangosteen tablets. As expected, these treatments didn’t work and they would come back months or years later, at a higher stage. By then, the treatments are much more expensive. Had they opted for treatment early on, it would cost them much less - and their cancers could have been cured.” 

She concludes: “These ‘No approved therapeutic claims’ treatment modalities and their advertisements should really be regulated.”

***

My colleague, whose request to remain anonymous underscores the sensitivity of this matter even among oncologists, raises insights that are worth reflecting upon, in light of the growing incidence of cancer - the third leading cause of death in the Philippines. What is the role of alternative medicines in cancer treatment? What benefits and dangers do they have, and what factors lead patients to choose them over biomedicine? 

To be fair, we must note that there could be a “selection bias” at work here: Doctors are unlikely to encounter the "success stories” of alternative medicine: they will not come back for follow ups. Instead they will be blogging and telling people about how they recovered. Indeed, patients can be “cured” by other means. In fact, even without any form of active intervention, some cancers can just disappear: “spontaneous regression” is a rare but well-documented phenomenon in the scientific literature. In real life, however, cancer is rarely left alone; people attempt various kinds of treatments, and when they do experience some improvement, in the absence of a definitive explanation, they will attribute it to something specific: the religious to divine intervention, the healthy eater to diet, the MLM networker to the pill or a product that they could better sell.

Nonetheless, while testimonials can magnify these miracles, statistics show a dire picture: without biomedical treatment, most people progress through the stages of cancer. In one Canadian study for instance, the 5-year survival rate was 86% for breast cancer patients that accepted conventional cancer care and only 43% for those who didn’t.

The lack of evidence for their claims, however, has not stopped people from marketing all kinds of products as cancer treatments. Some manufacturers trumpet on the wonders of a single herb, while others claim to gather all kinds of curative herbs in one tablet. Many of them make use of scientific terms (i.e. “antioxidants”, “cytokines”) to sound authoritative, invoking laboratory and animal studies that are scientifically insufficient but are convincing enough for the general public. 

They will also be advertised as “FDA approved”, as if it were an endorsement, even though the FDA only registers supplements as a matter of procedure and makes no actual evaluation of the products themselves or their claims. 

Finally, many alternative medicines are promoted as harmless vis-a-vis the well-known side effects of chemotherapy. Left unsaid is the fact that supplements, too, can have side effects and more importantly there is a heavy opportunity cost of each day that goes by without getting proven treatments. 

It is worth mentioning that others go even further, offering not just unproven treatments, but unproven diagnostic tools, using dubious methods such as special urine and blood tests, oftentimes with “high-tech”-looking devices. By “diagnosing” someone as having “cancer”, these quacks can then offer a treatment that is sure to work, as there was no disease in the first place. 

 

***

Complementary and alternative medicine (CAM) must be taken seriously for a number of reasons. Firstly, biomedicine should never shut its door to new knowledge. Vincristine and vinblastine - derived from an periwinkle long used in India and China as an herbal medicine - are now important anti-cancer drugs. Immunotherapy - once set aside in favor of immunosuppression - is showing promising results and is now an exciting avenue for research. Indeed, CAM shouldn’t be generalized as ineffective. Moreover, while biomedicine’s paradigm is treatment, other forms of healing focus on prevention, and their view that modernity itself - our diets, lifestyles, and environments - has become carcinogenic is something that we must seriously consider.

Secondly, the health care system should see these alternatives as symptoms of its own problems and shortcomings. Perhaps it is not able to allay people’s fears and misconceptions about the causes of cancer and its treatment options (i.e. surgery, chemotherapy, radiotherapy). For people who fear cancer, taking supplements has “symbolic efficacy” in assuring themselves that they are doing “something” about their perceived risk. Perhaps, too, the cost of cancer treatment remains - or is perceived to be - prohibitively expensive to many Filipinos. Surely, better PhilHealth coverage will relieve patients of the hesitation brought about by the threat of financial ruin (On a positive note, the Z-benefit package is a step towards this direction). 

Finally, alternative medicines speak of the toothlessness of the Food and Drug Administration in controlling the ways in which supplements and other products are marketed. Disclaimers such as  “No approved therapeutic claims” and the newer “hindi ito gamot” (This is not a drug) are meaningless when drowned by imagery and language suggest otherwise. While the FDA has done a great job in issuing public advisories against false claims, the fact that these claims are even allowed in advertisements underscores the need to give the FDA more regulatory teeth - and inter-agency support.

Ultimately, however, the decisions will have to come from cancer patients and their families. While it is easy to dismiss them as gullible or irrational, we must understand that they are caught in desperate situations in which there is nothing more attractive than hope, something that Western medicine itself cannot offer in clear and reassuring terms. 

Until a cure for cancer is discovered - or unless we step up efforts towards information dissemination and regulation - the search for alternatives will go on, and “merchants of hope” will continue to profit from people’s desperation and hopelessness. 

(Originally published in Rappler on December 2, 2016)