Doctors, Hilots, and Albularyos: Medical Care in the Philippines – Part Two

“Medicine heals doubts as well as diseases.”

– Karl Marx

One day, we are visiting Elsa's parents in Mawab when Risa shows up and says that her son two-year-old Zion is ill. He has had a fever for three days. She wants to visit a well-known Albularyo. She takes Zion to see the Albularyo when the medical doctor doesn't seem to have a treatment for an ailment (and besides, he's cheaper). We first take a ten minutes tricycle ride over a rocky road to Andili, the Mawab barangay where Risa is living with Zion's father Patrick. We reach their house and I climb down from the tricycle. A dozen or so children surround me, shouting and screaming. One touches me on the leg.

“They've never seen a white man,” says Risa. “You're a big hit.” Elsa later tells me that many rural children see me as a magical being – a fairy or elf.

We pick up Zion and head down the road to an even rockier, dirt side road that cuts through a grove of coconut trees. The tricycle bounces over ruts and fallen branches for a couple of kilometers or so before we come to a clearing where a small bamboo home stands – actually a lean to with one side made of a loose weave bamboo and the other side a half wall made from coconut boards and blue tarp. There is no kitchen and the only stove is a fire pit outside. A small, wizened man in his 50s, unshaven and wearing a t-shirt and shorts comes out to greet us. He is the Albularyo. Risa says he is a holy man and heals many people through prayer. The Albularyo massages Zion's head and body and gives him a drink of coconut water. He also feels Elsa's side and back and says she was injured as a child. Risa and her are amazed by his wisdom. I remain a skeptic.

Jaredt, Elsa's oldest daughter, with medicines given
during free medicine day in the purok.

The Albularyo's wife offers me a drink of coconut water. I take a few sips; it tastes bitter, and I don't like it. Later, Elsa tells me there are three types of coconut and the ordinary one that I drank doesn't taste as good as Macapuno or San Ramon coconuts. The next day, Zion seems better, which Risa and Elsa credit to the Albularyo's treatment, but I attribute to the fact the flu generally runs it's course in three days.

*****

I buy a fan. Elsa asks me to keep it away from her. Fans spread “bad air” and cause disease she tells me. She also doesn't want to walk in the rain – even drizzles – because rain presumably causes colds and flus. Such notions are not so strange – some westerners hold similar beliefs, but they seem much stronger and more persistent here. Among Filipinos, there seems to be an almost paranoid fear of walking in the rain. People will hide under umbrellas even during drizzles (although Filipinos more commonly use them on sunny days when you see dozens of people shading themselves under the safety of open umbrellas). Some teachers don't show up for work when it rains and, one day, during a drizzle at a local festival, hundreds of people squish together under a huge tarp rather than brave the light rain (the huddling together would more likely cause colds and flu). Rain can shut down some businesses. The general alarm reminds me of Seattleites concern when it snows.

One reason for this concern about “bad air” and rain may be because germ theory has never been as widely accepted in the East as in the West. Prior to Pasteur showing in the 1860s that germs, i.e., bacteria and viruses, cause disease, people throughout the world, in the West as in the East, believed that “bad air” was the cause of disease. This“miasma” view of the world seems still prevalent here. Maybe that's why many people rarely wash their hands and why many public facilities (including hospitals) have no soap; there's just not the same concern about germs found among Americans.

*****

We visit Ramon Bandong, a friend of Elsa's, hospitalized at the regional government hospital in Tagum with complications from diabetes. The regional is a larger hospital than Bishop Regan's although it has comparable 1950s style equipment and facilities. Ramon, who worked in the provincial government with Elsa, is confined to a public ward with at least 25 other people. Care is free at government hospitals unless you choose a private or semiprivate room. Mariz Bandong, Ramon's wife sits at his bedside. They are a handsome couple in their 50s. There is no privacy and there seems to be only one nurse treating patients on the ward. Mariz is also a good friend of Elsa's, a Women's Council President like Elsa who has worked with her on several projects. Ramon breathes laboriously. He is on oxygen and seems quite ill. Mariz tells us Ramon has been ill for awhile.

Ramon dies a month later and we attend the funeral, the first of many I attend in the coming months. We view the body in Nabunturan at St. Peters, a franchise funeral home. Elsa's friend Marie Vising owns the local franchise. We bring some biscuits to share with the other mourners, a typical gesture at Filipino funerals. I'm the only man inside the funeral home. A few other men remain outside. After paying our respects, Mariz shakes our hands and thanks us for coming. Before we leave, Mare Vising takes us on a tour of the facilities. She takes us up to the second floor where she rents out apartments to tenants just above the funeral home. From the second floor, we can see tombstones on graves at the public cemetery a few blocks away.

Ramon was about the same age as Elsa's husband when he died from cardiac problems. Early deaths seem more common here. The mortality rate from heart disease, stroke and diabetes is three times that of the U.S. and the average life expectancy is only about 67 or ten years less than in the U.S. I'm not sure if this is due to the lack of medical care or diet – most Filipinos eat prodigious amounts of white rice – a large plate of rice with every meal. Several medical studies of Asian populations have suggested eating more than two cups of white rice a week is strongly correlated with diabetes, stroke and heart attack. Fried fish is the other staple and it's usually cooked in highly saturated palm oil.

*****

We visit Dr. Concepcion Balunos, Elsa's gynecologist, at Tagum Doctors' Hospital. This hospital seems a little more modern than Bishop Regan and the facilities are in the midst of an update. Still, the CRs have no soap or toilet paper and the doctor's offices have plywood ceilings and cramped spaces. Dr. Balunos is a middle-aged woman, pleasingly plump, and personable with a caring manner. She spends more time with her patients than physicians do typically in the U.S. and discusses personal issues with Elsa, not just her medical condition. Dr. Balunos is one of our godparents and because of this relationship, offers us free consultations. Being a godparent at one's wedding is more than just a ceremonial occasion, but a lifelong obligation here in the Philippines.

I haven't completed my overseas inoculations and ask her about them. She administers the second of my Hepatitis B shots. I need my second inoculation against Hepatitis A, but there is none available for adults. There are also no vaccines against rabies or Japanese Encephalitis, injections I didn't have in the U.S. because I was expecting to get them much cheaper in the Philippines. I also ask Dr. Balunos whether MRI is available in Tagum since I recently developed a neuralgia condition that was diagnosed using MRI. She tells me there is a new MRI machine, but it hasn't been set up yet and we will have to travel a couple of hours to Davao to find a functioning MRI.

The hepatitis B vaccine was much cheaper than in the U.S. – it costs about $15, much less than the injection I had in the U.S. I do have to purchase the vaccine in a pharmacy and carry it back to Dr. Balunos office where she administers the injection – different from the U.S. where the vaccine would be available in the medical facility, not a pharmacy, and would be administered by a nurse or technician – rarely, if ever, a doctor.

Many medicines are cheaper than in the U.S., but some are not available or some are much more costly. Preparation H for hemorrhoids typically costs $5 to $10 in the U.S. I attempt to buy it at a local pharmacy in Tagum, but a small tube costs almost $50. I buy a local hemorrhoid medication and it still costs over $10 for a small supply of suppositories. Statins are widely available and relatively inexpensive – about 50 cents a tablet. Some prescription drugs are sold without a prescription – illegal, but not an uncommon practice here.

Most medicines come in strips of five or ten tablets, not the month or three month supplies sold in bottles in the U.S. Paracetamol, the Tylenol generic, is the most commonly used painkiller here. Ibuprofen, while available, is not commonly used and aspirin even less so. Elsa's daughter Kristna tells me she tried aspirin for a headache, but it didn't prove helpful. I latter find that aspirin typically comes in 80 mg pills, the size sold for children in the U.S., and a dose too small to be helpful for most adults.

David Wasson, a U.S. expat friend of mine who started the Tagum City Food Bank, is admitted to Mission Hospital for back surgery. I visit him at the hospital and ask about his pain medication.

“They just give me Paracetamol,” he tells me.

“No morphine, codeine or oxycodone? I ask.

“Doctors here won't give stronger drugs than Paracetamol because they think they're too addictive.”

I hope I never have to have surgery here.

Dental care also is problematic in the Philippines. Filings, crowns, and root canals seem uncommon here. The poor cannot afford dental care and so if they experience tooth pain, they simply have the tooth extracted. Many of those over the age of 50 have only three or four teeth left.

Elsa needs some bridgework, and I need a cleaning, so we visit a dentist Lorna has recommended. We take a tricycle down Pioneer Street to an old, dilapidated building in downtown Tagum. The dentist's office is a cave like space at the corner. We climb down some stairs into a dark and dank reception area with a concrete floor, low ceiling and unadorned concrete walls. It looks like a tomb. Again, we have no appointment, so we take a seat and wait. Three people appear to be waiting for treatment. As we take our seats, one of them rises from his seat and goes to a desk and signs us in – he's the receptionist and not a patient.

We wait about an hour before the receptionist finally motions Elsa inside and motions me to follow. The treatment room is just four bare concrete walls with a curtain separating me from the chair where the dentist works on Elsa's teeth. There's only one chair and one dentist. The only decorations on the walls are some embroidered cloth horses. The dentist, a portly, slightly disheveled man in his 50s works in his jeans and a white shirt. He only wears one latex glove.

While the dentist is fitting Elsa's appliance, a seven- or eight-year-old child wanders into the treatment room. He reaches behind a side wall for a banana and eats his snack in the treatment room. Then the dentist's wife comes into the treatment room and starts texting. Such is privacy here in the Philippines.

The dentist finishes with Elsa and asks me to take her seat. He asks we when I last had a cleaning. About nine months ago I tell him – the longest time I've gone without a cleaning in years. I usually have three or four cleanings a year. He is surprised my last cleaning was so recent.

“We usually only do a cleaning once a year,” he tells me. He does a minor visual examination of my teeth then applies some polish. The cleaning seems superficial and he doesn't probe my teeth for bleeding or loose pockets. The treatments are cheap though – less than 3,000 pesos (about $65) for Elsa's new partial plate (pustiso) and only 300 pesos (about $6 or $7) for my cleaning. Such is health care in the Philippines. 

Doctors, Hilots, and Albularyos: Medical Care in the Philiippines – Part One

“If you are poor in the Philippines, and you have no political connection, and are not known to the medical service provider, and if the latter thinks you have no education, you are likely to die.”

– Danilo Reyes in an article published by the Asian Human Rights Commission.

One reason many expats cite for moving to the Philippines – you can obtain medical care as good as in the U.S. at much less cost. The doctors are well-trained, often in the U.S., and the hospital facilities excellent. This is true – if you live in a major metropolitan area such as Manila, Cebu, or Davao. Outside of these major urban areas, a quite different picture emerges.

In these areas, not only are the facilities substandard, medical equipment and technology outdated, and medicines and technology such as MRI rarely available, but access to them can be difficult. On top of this, traditional beliefs often undermine proper recourse to treatment. Because of prohibitive cost, people will seek care from traditional healers before going to the hospital often complicating or compromising their care.

For expats, and those who have more money, health care is more readily available. But for those who live in extreme poverty, (over 25% of the population according to the Philippines government), medical care remains almost nonexistent, particularly here in the southern Philippines where in some provinces almost 50% of the population lives below the poverty line.

The national health care plan, Phil Health, provides some support, but typically covers only about 40% of medical costs. The cost is cheap for expats, but among the poor even the modest Phil Health fee of 200 pesos a quarter is prohibitive. So they resort to traditional medical practices like Hilot (a form of reflexology) and herbal treatments from folk healers such as the Albularyo.

Image courtesy of  www.nerdygaga.com/

Hilot is a 1,000 year-old healing tradition still commonly practiced here in the Philippines. The Hilot practitioner is typically a midwife who sets broken bones through massage. However, Filipinos consult Hilot practitioners for all kinds of conditions, not just musculoskeletal conditions for which you might think massage would be useful, but for flus, colds, and just about any condition.

The Albularyo focus on diagnosing imbalances in the body. They feel your pulse or use mystical means to tell which of the four elements (earth, water, air or fire) in your body is imbalanced. After the diagnosis, they use Hilot and/or herbal medicines to treat the imbalance.

Mothers in Montevista receive free medicine from Bridgettine nuns.
            Such donations at the only source of medicine for some of the poor. 

Associated with faith healers and popular religiosity, it's easy to dismiss these traditions as superstition. I find my Western skeptical mind going there often, but some commentators have pointed out that this is a judgmental term used by dominant religions to categorize and denigrate earlier, less sophisticated religious attitudes and behaviors. Others argue that these practices represent a rejection of colonialism and an attempt to cope with the experience of oppression.

Nonetheless, some of the practices seem bizarre to my skeptical Western mind. One day I have a cold and one of Elsa's friends rubs an egg in the crook of my arm and then spins the egg on a table, supposedly divining the seriousness of my illness. Another time, the family dog bites a neighbor's child and Elsa takes the child to see an Albularyo in Nabunturan. He proceeds to lay his hands on the child's head, making a fist with one hand and laying the other hand against it as a barrier. He whispers an incantation into the fist, then spits on his thumb and rubs the spittle into the wound. He repeats this process three times. I'm hoping the spittle isn't giving the child an infection.

“Why go to an Albularyo for this treatment?” I ask Elsa.

“He is gifted in diagnosing rabies,” she says. I shake my head. Fortunately, Elsa also recognizes the need to send the child to a doctor for an injection.

* * * * *

One day, Elsa complains of pain in her chest. It's a chronic problem that she attributes to an injury sustained when she was three years old and living in Ilo Ilo. Playing in the kitchen, she fell through a hole in the floor on her family's pole house (a bamboo hut raised on stilts). Her mother called in a Hilot to treat Elsa. I'm wondering if the massage contributed to the problem since it doesn't seem like reflexology would help with a bruised or broken rib. The pain arises periodically to this day.

After enduring the pain for a couple of days, Elsa's friend Lorna tells her about a new Hilot she has consulted who employs a rougher form of massage. Elsa wants to try it out. She suggests I try the Hilot as well since I'm suffering from bronchitis. (I seem to be constantly fighting off a cold or diarrhea or stomach flu). I tell her that the bronchitis is due to a virus and no amount of massage or chants will help, but she insists I try. I want to see what it is like anyway. So I agree to give it a try.

So the next morning, we walk past the provincial capital, turn left on Pioneer, and up a couple of blocks where we turn into a subdivision made up of narrow rows of hollow block homes – Villa Magsanoc Subdivision. Lorna's house is on the corner one block from the highway. Vines and flowers hide the entrance.

“Ayo Ayo?” calls out Elsa (“is anyone home?”). A heavy set woman opens the door and leads us to a small sofa where we take a seat. She is Lorna's cousin visiting from Lanao in northern Mindanao. Lorna has a sari sari store attached to her home where she sells snack foods, soft drinks, cigarettes, seasonings, instant coffee, Milo (a chocolate and malt powder) and laundry products. The sari sari store is a popular alternative to the convenience store found throughout the Philippines.

Lorna's cousin enters the store and gets us some cheese filled crackers and soft drinks. The Hilot is already there – a heavy set man in his 40s. He massages Elsa first. She cringes a little as he kneads and pulls. After a few minutes, he finishes and motions to me.

“How was it?” I ask Elsa.

“Rough,” she tells me. I take a seat and he begins. He kneads my back and shoulders and legs and the pads between my thumbs and forefingers. He is rough and it's painful and I don't want to ever try it again, especially since I don't notice any results for Elsa or me.

Hilot is not just for the superstitious or uneducated. Lorna, a widow in her 50s and a cancer survivor, initially sought treatment from a medical doctor, but with the cancer in remission, she now chooses to use herbal medicine. Even though she is well-educated, a chemical engineer by training, she prefers traditional Filipino herbalism to modern western medicine (perhaps if I had had to go through radiation therapy, I might feel similarly).

For Elsa, the pain doesn't get any better and finally she asks me to take her to the hospital. She is convinced she has a heart problem. We take a tricycle to Bishop Regan Hospital and walk in through the emergency entrance. The facilities remind me of something from the 1950s with plywood walls and ceiling, old, stained tile floors and cheap wooden counters – not at all the spanking, new, antiseptic appearance of American hospitals.

While the technician takes Elsa's information, I go to the comfort room (bathroom) and here, even in the hospitals, there is no soap, no flush toilet and the facility reeks of urine; there doesn't appear to be a semblance of regard for cleanliness and hygiene. The emergency room consists of a wooden desk with a few plastic chairs scattered around and a couple of old crank up style beds with thin mattresses. They look like donations from a 1940s U.S. Army hospital.

A few health care workers are milling around; I don't know who's a doctor, or a nurse or an aide. Finally a man in a blue hospital gown comes over and takes Elsa's blood pressure. He motions her to lie down on one of the beds. There are splotches of dried blood staining the sheet. The man wheels over a cart equipped with an old EKG machine. He pulls an old, cloth curtain around one side of her bed, and I sit in a plastic chair at her feet. The man starts to attach wires and heavy metal clamps that look like car battery cables to Elsa's chest.

We get the results immediately – normal. We go to the counter and pay our 200 pesos (about $4) – at least the cost is low. The health care worker suggests we consult with Elsa's doctor in Mawab. Unfortunately, he's out of town and so we visit another doctor, Dr. Sanchez, in Nabunturan.

The next day, we take a bus to Nabunturan. We leave the terminal and the bus winds up a hill and through the mountains until the road descends about 30 minutes later into a river valley where we pull into the Mawab bus terminal. We wait for 20 minutes or so before the bus continues on its journey to Nabunturan (the provincial capital of Compostela Valley, halfway between Mawab and Montevista where Elsa has her house).

The name “Nabunturan” means “between the mountains” and they seem to disappear as we drive on past rice fields and stands of coconut and banana trees. We arrive at the Nabunturan terminal about 20 minutes later and take a tricycle to a nearby clinic where we meet Dr. Sanchez. She examines Elsa and reads the EKG results. She orders a chest x-ray and charges us about 250 pesos for the x-ray and about the same for her consultation.

A week later, we return to Mawab and finally see Dr. Brigas. We arrive just before noon and he is at lunch, so we sit and wait. There are rarely set appointment times with doctors here. You just show up and wait in line often for an hour or more. Specialists will take appointments, but even so, you may wait for a considerable amount of time because there are insufficient numbers of specialists.

Dr. Brigas finally meets with us. He is a handsome, affable man who looks to be in his 40s. He says that the test results are all negative. He tells me he is the family's doctor and has treated Elsa for years. On several occasions in the past she has experienced chest pains that led her to fear heart problems and she has frequently consulted with him always with the same results.

“It's just muscle pain,” he tells us. “Muscle pain and anxiety.” The muscle pain probably comes from her old injury, and is exacerbated by her anxiety. He prescribes Xanor (called Xanax in the U.S.) an anti-anxiety medication that also seems to relieve some muscular pains. Almost immediately, Elsa says the pain goes away. She takes a low dose once every week or two and, when the need arises, consults a hilot, and that seems to sufficiently manage the pain for awhile.