Drugs, supplements, and Universal Health Care

by Gideon Lasco, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Manila
September 14, 2012

REFERENCES

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

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

Reproductive health, HIV/AIDS, and Foucault's "History of Sexuality"

by Gideon Lasco MD

The medicalization of our lives cannot be discussed without juxtaposing it with the commercialization and politicization of the medical. By transitivity, the medicalization of our natural processes is the commercialization and politicization of such, and in this way, medicine becomes a route, among others, by which our bodies are subjugated by politico-economic regimes. Following this premise, behavior, even sexual behavior, can be produced by these regimes, by way of and as seen in discourse, or how things are discussed as distinguished from what people actually do. This, I think, sums up what Foucault depicts in the first volume of his "History of Sexuality"; the juxtaposition that I described is what he terms as "biopower" and the discourse on sex is what he ascribes to as the author of “sexuality”.

In History of Sexuality, Foucault rejects the notion that sexuality was repressed; in fact, there was, in fact, an “incitation to discourse” (p. 33); a “need to talk” about sexuality, traceable to the Christian tradition of confession. He builds the case for this “need” for sexuality across different cultures, citing the ars erotica of the Japanese and the Indians and, within Western culture, the divergent but in some ways analogous concept of scientia sexualis. But instead of simply concluding that the a priori need to articulate sex is a cultural universal, he deftly connects it with his central theme: the production and use of power. In fact, it is this very “biopower” that has produced sexuality as we know it (p. 105).

It is not difficult to apprehend the implication of Foucault's book on the overarching themes of reproductive health, sexuality, and HIV/AIDS.  If sexuality is "produced", then reproductive health, too, is a product, and it can be "reverse engineered" to yield the secrets of its construction. Likewise, the intimate relationship between sexuality and AIDS becomes situated in the "embeddedness" of sex in relation to power.

Which begs the question: by what method? Herein lies the significance of Foucault: he lays down the theoretical foundation of anthropology and sociology as methods for the understanding of sexuality (and by extension, its intimacies). Indeed, by emancipating sexuality from sex (and thus, from the realm of the biological, the inevitable), Foucault makes it a valid focus of social science research. we can then think of heterosexuality, homosexuality, bisexuality, and other “genders” as “imagined sexualities” [1].

In approaching HIV/AIDS, thus, we too must look for the “repressive hypothesis” to debunk, we must look at the discourse, and at the practice. A spectrum of approaches then emerges: from micro, in-depth observational studies on what is actually practiced (a paean to ethnography) to macro, ecological, critical observation that looks at “biopower” (i.e. critical medical anthropology). Among the firstfruits of this approach include the use of concepts like “structural violence” that actually elaborate the relationship between power structures and HIV/AIDS in more discrete terms [2].

Foucault’s paradigm not only shapes and legitimates methodologies, it also influences interventions. For instance, the categorization of people as “men having sex with men” instead of “gay” or “homosexual” is in a way an application of the social constructionism that Foucault espoused.

Perhaps a useful thought experiment on reproductive health would be to imagine a future when (in)fertility can be perfectly controlled by biomedicine – a total schism between recreation and procreation. Or perhaps we can imagine a world where sexually-transmitted diseases have been completely eradicated. Via Foucault, we can navigate through these imagined worlds by discussing it in terms of biopower, the deployment of alliances (p. 115), which itself can lead us to reject the very possibility of these worlds’ coming into being. In these imagined words, there is at least a Foucaultian trajectory by which we can commence our speculations. I can begin by suggesting that only a complete liberation from any form of pathology can liberate us from the regimes of biopower.

Ultimately, by inextricably linking medicine and our bodies with politics and economy, i.e. the "power without the king" (p.91), Foucault's book lays down the premise that upholds the importance of context. As we continue to confront HIV/AIDS and reproductive health issues, embedded as they are in a myriad of issues, the centrality of Foucault‘s message cannot (and should not) be lost. Indeed, the voice of anthropology is essential in HIV/AIDS studies if we are to put an end to the epidemic. Foucault may yet help kill the illness that claimed his own life.

Brussels, Belgium
January 28-29, 2012

NOTES

1. The allusion on Benedict Anderson’s “Imagined Communities” is intentional. Anderson’s assertion that the concepts of nations, too, are constructed, is as revolutionary as Foucault’s notion of sexualities as constructs.

2. Here I am thinking of Paul Farmer’s Pathologies of Power and also some of Vinh-Kim Nguyen’s works.

3. As a final thought on History of Sexuality, it can be suggested that Foucault’s work is itself part of “discourse” (or, anti-discourse) that legitimates criticism of “biopower” (anti-power).

SELECTED BIBLIOGRAPHY

Foucault, M. (1978) The History of Sexuality Volume I: An Introduction, translated by R. Hurley. London: Penguin Books

Anderson, Benedict R. O'G. (1991). Imagined communities: reflections on the origin and spread of nationalism (Revised and extended. ed.). London: Verso.

Farmer P (2003). Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley, Cal.: University of California Press

Young R, Meyer I (2004). The Trouble With “MSM” and “WSW”: Erasure of the Sexual-Minority Person in Public Health Discourse. Am J Public Health. 2005 July; 95(7): 1144–1149.

Notes on the folk medicine of the Rizalistas in Dapitan

A replica of Rizal's house in Dapitan, where he was exiled for four years
(G. Lasco, 2010)

By Gideon Lasco, MD

DAPITAN – The Rizalistas here converge around Rizal Park in Brgy. Talisay, where Jose Rizal stayed in exile for four years (1892-1896). They have homes built within the vicinity of the park, and they have an alleged membership of a few thousands. Most of them come from Dapitan, Dipolog, and the surrounding towns of Zamboanga del Norte.

On August 28, 2010, I conducted an discussion among three women and one man, aged 60, 32, 55, and 67 respectively. I also interviewed their most experienced manghhilot, who introduced himself as Isidro, while he performed the hilot (therapeutic massage) on me for one hour. Furthermore, I conducted interviews with other Rizalistas as well as residents of Dapitan from August 27-29. The information I derived from these discussions are by no means exhaustive nor comprehensive; they are merely offered as a glimpse of the Dapitan Rizalistas’ philosophy and practice of folk medicine.

Their philosophy of healing may best be gleaned from how the view Rizal the healer. Significantly, our informants ascribe Rizal’s healing prowess not only to his medical education in Europe, but also to his inherent spiritual power. They also say that Rizal practiced hilot (therapeutic massage) in Dapitan, and that he employed herbal medicines. When asked if they know of any account, by either written document or oral tradition, about the particular herbs Rizal used, if any, they were not able to give an answer. However, in the correspondence between Rizal and Blumentritt while the former was in exile, the claim of Rizal’s use of herbs seems to be corroborated.

Our informants acknowledge that much of their medical tradition was taught by their founder, which they call Mahal na Haring Filemon, who is still living at age 79. Interestingly, however, they claim that their source of knowledge is ultimately Rizal still, and it is through revelation that this knowledge was conveyed to them via their founder.

The practice of folk medicine among the Rizalistas is limited to two components, namely pharmacotherapy (gamot) and therapeutic massage (hilot). Arguably, there is a third, inherent, spiritual component; this is expected for the Rizalistas are first and foremost a spiritual group which recognizes the deity of Rizal in varying degrees.

The pathophysiologic basis of disease is derived from prevalent folk theories of illness causation, though syncretism is observed: terms such as high cholesterol and uric acid have entered their body of medical knowledge, creating an interesting amalgam of beliefs. The acquisition of Western terms has given rise to simplistic explanatory models for particular illnesses. For instance, hypertension is seen simply as a state of high cholesterol; whereas various arthritides are attributed to elevated uric acid. Elemental forces, such as lamig and hangin, are seen as etiologies of both primary diseases and complications. Despite the use of these terms, however, there does not seem to be a coherent, systematic theory of pathophysiology.

There are only two drugs used as therapy: one is a dark red, concentrated syrup called dugoang serap; the other is called ‘fire capsule’ and is said to be derived from the plant called ‘luyang kahoy’. Both have a wide range of alleged therapeutic indications.

Dugoang serap (perhaps serap is a corrupted form of ‘syrup) is derived from the bark of a tree called dugoang kahoy. I was instantly reminded of a folk therapy I was given on the deep jungle of Mt. Mantalingajan by a Tau't Bato panglima: when I complained of weakness (we had been climbing for 4 days, 11 hours a day), they got a bark, which, when dipped into water, turned the water red. They call it 'dugong halaman'.

Dugoang serap is said to be curative for leukemia, hepatitis, dengue fever, mga sakit sa dugo, binat, and many other diseases and disease categories. A teaspoon of the syrup is mixed with hot water and the concoction is drank like coffee, once or twice daily. A 375mL bottle costs 1000.

The potency of dugoang serap draws from the belief that blood is life; therefore, intake of a blood-like substance is life-sustaining. This will also figure in the discussion of hilot, or massage.

The other pharmacotherapeutic agent is the fire capsule, which is allegedly derived from the bark of a plant called luyang kahoy. This tablet is particularly useful for kidney and gastrointestinal problems, but is also effective for cancer, ulcer, heart disease; it is essentially promoted as a panacea. The dose is once daily, but if one wants quick results, a single dose of 5 capsules can be ingested. Moreover, dose is faith-dependent; a person with much faith can get by with just the minimum of dosages. Each capsule is sold for 20 pesos.

Finally, hilot itself is employed as therapy; a “ten-step technique” is taught by the group’s founder. The massage is officially called “Philippine New Life Therapeutic Massage” and is said to be both a “spiritual” and “material” massage. The “spiritual” component is allegedly the inherent healing power within the healer, that can be boosted by faith and spiritual acts such as prayer and penitence.

The explanatory model for the ‘mechanism of action’ of the hilot is interesting. According to Isidro, the blood vessels are the primary target of the massage. The kneading action stimulates the blood vessels, strengthening them:

Kapag hinihilot, yung mga ugat ang hinahanap…Ang dugo ay nagiging bago, nalilinis. (When you do the 'hilot', you're searching for the blood vessels. The blood is renewed, cleansed)

The cleansing effect on the blood is then connected to the lowering of cholesterol, saying that the stimulation of the blood vessels cause the dislodgment of cholesterol plaques. Washing of laundry is used as metaphor:

Parang labada na may mantsa, kapag nakusot, nawawala, nalilinis…Ganun ang nagagawa ng hilot kaya kailangan may training para alam kung ano dapat ang hilutin. (Just like laundry that has stains, if you scrub it, the stains get removed; they are cleaned. That's what hilot does that's why you need the training so you know what to massage)

When asked however how the ‘blood vessel’ theory of massage can explain pain relief, Isidro answers that a secondary target of the massage are the nerves, the realignment of which can relieve pain. Interestingly, there is little distinction between blood vessels and nerves in the Tagalog and Bisaya languages; for many speakers ugat can pertain to both. Isidro, while performing the hilot, was able to correctly identify and locate many blood vessels and trace their course in the human body. Gentle massage of the femoral vessels, he said, while massaging the femoral area, can strengthen a man. Impotence, he added, can be alleviated by massaging the hypogastric and inguinal areas, with improved circulation in mind.

Hilot, like pharmacotherapy, has many indications; but it is seen as the weaker form of therapy, used for mild cases and for general well-being, except in some instances where it is seen to be a superior therapy (e.g. in the case of impotence). The hilot has to be performed in a sequential manner, or else the efficacy would be greatly diminished, if not nullified. The need for a proper sequence draws from the spiritual aspect of the hilot.

The Rizalistas in Dapitan are an interesting focus of study because they exemplify many of the Filipino folk beliefs and values regarding medicine. The spiritual component of healing figures prominently; and the folk theories of disease causation are still used, albeit with substantial borrowing of concepts from Western medicine. I believe that a more in-depth study of their beliefs and practices, and perhaps a comparison among various Rizalista groups according to geography, would be a good direction for research.

Dapitan
August 29, 2010

Circumcision or Mutilation? A critical appraisal of a study that finds PTSD among circumcised Filipino boys

A boy gets circumcised during a surgical mission in Palawan, Philippines (Gideon Lasco, 2014)

A critical appraisal of the study entitled “Ritual and Medical Circumcision among Filipino boys: Evidence of Post-traumatic Stress Disorder” by Samuel Ramos and Gregory Boyle

By Gideon Lasco, MD 

To all Filipino males out there: Would you entertain the thought that as a child, you were “mutilated” and “criminally assaulted” through the procedure of circumcision? An Australian study says just that.

In a paper entitled “Ritual and Medical Circumcision among Filipino boys: Evidence of Post-traumatic Stress Disorder” published in 2000, authors Samuel Ramos and Gregory Boyle studied circumcision among boys aged 11-16 in Batangas, a province in Southern Luzon, Philippines. According to their findings, a majority of the boys had post-traumatic stress disorder after circumcision, and uses the findings to support the general statement that circumcision is a form of physical violence.

How valid is their paper? Can circumcision, which is accepted by over a billion people, be in reality a form of mutilation? This piece is an exercise that critical explores the connection between the “anthropological reality” presented by the authors and the “emic reality” as experienced by myself, who belong to the culture that is the subject of the paper.

This piece uses the qualitative critical appraisal questionnaire by the Critical Skills Appraisal Programme network (http://www.casp-uk.net/).

1 Was there a clear statement of the aims of the research? 
The authors state that they aim to investigate the psychological consequences of “partial penile amputation”. The authors then connect the relevance of this study in building the case that the Filipino practice of male circumcision is “in reality, criminal assault. Evidence of post-traumatic stress disorder (PTSD) would be used as the parameter by which psychological consequence (i.e. harm) would be measured.

2. Is a qualitative methodology appropriate? 
To their credit, the authors employed qualitative methods, which comprise the first half of the paper. Thereafter, an interview is sent out. For such a sensitive, multi-factorial topic such as circumcision, qualitative methods are truly appropriate to make sense of the practice, whether or not in conjunction with a quantitative paper.

3. Was the research design appropriate to address the aims of the research? 
The research design calls for the measurement of post-traumatic stress disorder (PTSD) among children who underwent circumcision; an outcome showing PTSD is then used as a justification in labeling circumcision as “violence”. They used the DSM-IV criteria (a listing of psychiatric conditions) to define PTSD.

There are serious flaws in the research design. In the first place, the very premise of the study is the diagnosis of PTSD according to the DSM-V criteria. How valid is the DSM criteria, especially when doing cultural research? To show how dynamic and arbitrary this criteria is, homosexuality was once part of DSM-II, and today there is growing criticism of DSM particularly with its cross-cultural applicability (Kleinman, 1987; Faraone and others, 2003, Hinton and Fernandez, 2011). Circumcision definitely presents with pain but there is a need for a much deeper analysis before someone becomes qualified to say that it is “violence”.

PTSD is defined in the DSM-V as a condition that "may develop after a person is exposed to one or more traumatic events, such as sexual assault, warfare, serious injury, or threats of imminent death" (APA, 2013), and thus it is highly questionable for circumcision to be included in this category, given that while it presents with "pain", it is a very tolerable kind of pain that is indeed likened as "kagat lang ng langgam" (just like the bite of an ant). In circumcision missions I have attended, it is the boys themselves who volunteer to be circumcised, and there is no sign of emotional trauma on their part after the procedure.Whether or not the boys in questions actually had (or have) PTSD can be subject to further technical questions in many levels.

Finally, the short-time frame given to the study limits its reliability. There are culturally-sanctioned forms of short-term pain and suffering which would find vindication in the future.

4. Were the data collected in a way that addressed the research issue? 
If research issue is “prevalence of PTSD among Filipino boys who undergo circumcision”, the sample is limited and cannot represent the population in question. Moreover, if the research issue is expanded to deal with issues of “harm” and even “criminal assault”, then measurement of PTSD alone gives the researchers with very limited, weak data.

5. Has the relationship between researcher and participants been adequately considered? 
The bias of the researchers on the practice in question is glaring throughout the paper, evidenced by their semantics. For instance, the use of “mutilation” is preferred in this paper, which itself indicates a value-judgment. In effect, the researchers have already stated their preference for the ultimate outcome of their research in question.

6. Have ethical issues been taken into consideration? 
Since the respondents are minors, there are issues of informed consent and confidentiality. Steps undertaken to address these were mentioned in the paper. Ethical approval was also given by their home university in Australia, but I would think that ethical approval from a panel in the Philippines would have been more appropriate.

7. Was the data analysis sufficiently rigorous? Is there a clear statement of findings?
Hasty generalizations abound in the data analysis. For instance, the paper declares: "Despite some methodological limitations, the present study clearly demonstrates the causal role of circumcision in the development of PTSD among Filipino boys." The use of “Filipino boys” is already a misrepresentation, because they were just studying a small section of a province within the Tagalog region.

The next statement is even stronger : “Evidently, there is strong evidence of a causal relationship between circumcision and resultant psychological trauma.” Again, this sweeping claim is not backed with any hard evidence,

The study also does not study the converse of the population, i.e. non-circumcised boys, and whether or not they had any “psychological trauma”. The embeddedness of both circumcised and non-circumcised males within society is ignored, and in this study, only psychological factors are considered, without any attempt to contextualize the definitions to the local culture.

8. How valuable is the research? 
Circumcision is an important practice in the Philippines and many parts of the world, and has been extensively well-documented. However, a research that gives judgments based on a very weak methodology and biased investigators cannot be assigned much value in this growing body of literature on ritual circumcision.

CONCLUSION 
This paper is an example of how “sociological” and “anthropological” studies coming from the outsiders’ (i.e. etic) perspective can be out of touch with the reality they claim to study. Circumcision is as detached from mutilation as an anthropologist is from a judge. Yet, this case underscores the need for us Filipinos to study, understand, and appreciate our own culture. Going back to the circumcision study, the researchers declare: “[Circumcision] is in reality criminal sexual assault.” In reality? Perhaps there is such a thing as an "anthropological reality", portrayed by social scientists and anthropologists, and then imagined (and reimagined) by the rest of the world. If applied on a culture, it can lead to (mis)perceptions that remind us that we have to be a voice in defining our own reality, for if we do not, others will.

REFERENCES
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. pp. 271–280.

Faraone, S. V., Sergeant, J., Gillberg, C., & Biederman, J. (2003). The worldwide prevalence of ADHD: is it an American condition?. World Psychiatry, 2(2), 104.

Hinton, D. E., & Lewis‐Fernández, R. (2011). The cross‐cultural validity of posttraumatic stress disorder: implications for DSM‐5. Depression and anxiety, 28(9), 783-801.

Kleinman, A. (1987). Anthropology and psychiatry. The role of culture in cross-cultural research on illness. The British Journal of Psychiatry, 151(4), 447-454.