Manny Pacquiao and the Filipino fear of blood extraction

by Gideon Lasco, MD

In 2009, the much-anticipated “Fight of the Century” between Manny Pacquiao and Floyd Mayweather, Jr., did not materialize, and one of the reasons cited was Pacquiao’s refusal to undergo blood testing before the fight – one of the conditions demanded by his would-be opponent. “I cannot understand his decision,” one sports commentator from The Guardian said, reflecting the general reaction of pundits from the West at the time.

Filipinos, however, were more understanding of Pacquiao’s refusal. "As long as they're not getting a large amount of blood, I am willing to give out blood as close to two weeks before the fight,” he had told a local newspaper. His own explanation – that such a procedure would make him feel weak – was entirely consistent with a belief held by many other Filipinos about blood and blood extraction, and did not diminish the ‘macho’ image and high regard that the Pambansang Kamao continues to enjoy in his country.

More disconcerting than a boxer’s refusal to undergo blood testing, however, is the refusal - or at least the reluctance - of many Filipinos, especially males, to undergo blood tests. A policeman perhaps expressed this apprehension best when he told me: “Tamaan na ako ng bala, wag lang karayom!” (I’d rather get hit by a bullet than get punctured by a needle!). A showbiz headline once read, referring to a famous actor: “Sa kabila ng ka-machohan, Derek takot sa karayom” (In spite of being ‘macho’, Derek afraid of needles). In the Philippine General Hospital, some of our patients would complain: “How I can recover if you’re getting too much blood from me?” Many doctors would be dismissive of these concerns because the usual amount of blood drawn - 5 cc - is medically insignificant, even on a daily basis.

But what is it in blood extraction that causes fear and apprehension among some Filipinos, especially among males?

First, we have to look at folk physiology, or people’s beliefs on how the body works. Many Filipinos think of blood in terms of being “malapot” (viscuous) or “malabnaw” (watery). Normal blood is seen as being in between these two opposing concepts, which are also used by people to make sense of a number of illnesses. High blood pressure is associated with malapot, while anemia and “low blood” are associated with malabnaw. Blood extraction, too, is believed to cause blood to be more malabnaw, hence the weakness.

Consequently, foods that recommended after blood extraction (or blood donation) are consistent with foods that are pampalapot or those that cause the blood to be more viscous. These include balut (duck eggs) and beer. Because blood is seen as at risk for evaporation because of the afternoon heat, those who had recent blood loss including blood extraction are advised to take a bath in the morning.

Many of our patients also think that the blood we have in our bodies is much less than the 5 litres a normal adult male has. This underestimate makes it more understandable for people to be concerned about losing a syringe-ful of blood, let alone the 500 cc in blood donation.

Why is this fear more common in males? Perhaps this is because females, owing to their monthly menstrual period, are more used to blood loss. Also, the being ‘malabnaw’ of blood may be seen as influencing the quality of semen. Some of my patients mentioned the belief that the ‘second round’ of sexual intercourse cannot lead to a pregnancy because the semen is malabnaw. Finally, there might be a fear not just about the blood loss itself, but what the laboratory tests that come after can reveal. We do see patients who do not want to find out about possible diseases in their bodies, thinking that the knowledge of the diagnosis, more than the diseases themselves, can do them harm.

Blood figures in our culture as a symbol of emotion, vitality and kinship. We speak of family as “kadugo”, of heritable traits as “nasa dugo”, and of anger as “kumukulo ang dugo”. But beyond these symbolisms of blood, we need to further examine what is possibly a significant determinant in people’s health-seeking behaviors. Many diseases can be detected through blood tests, and early detection can mean a greater chance of successful treatment or cure. Unfortunately,  many Filipinos delay consult until a disease is severe, and though lack of funds is generally blamed for this reluctance to seek medical attention, surely there are cultural factors we need to consider.

The Philippines has one of the lowest blood donation rates in the world, with 40 per 10,000 in 2010 compared to 73 in Indonesia and 187 in Malaysia. We feel this dearth acutely in hospitals, where blood is always running out, especially during times of dengue outbreaks. Can this low figure be associated with perceptions of blood extraction? The same may be asked of HIV testing, which also suffer from a low rate in a country where HIV cases are on the rise.

***

The Pacquiao-Mayweather fight is finally pushing through in May 2, and based on news reports, Pacquiao seems to have acquiesced to the drug testing measures. Surely, his reservations about blood tests are still there, but he has let go of them for the sake of “Fight of the Century”.

This should serve as a positive example for many Filipinos who are reluctant to undergo blood tests, or donate blood. Just as Pacquiao might have realised, there are more fearful things than loss of blood. Not getting a chance to fight - be it a boxing nemesis or an otherwise-treatable disease - is one of them.

More than a celebration of love

by Gideon Lasco, MD

Red roses, Swiss chocolates, romantic candlelight dinner dates: Such are the images that we conjure and strive to enact during Valentine's Day. Listen to the radio and even the songs that were played during your JS Prom are brought back to life. This reminds me that in my high school days, "Who's your Valentine's date?" was the question that gave voice to the peer pressure to have someone on February 14.

Oftentimes we accept these things as part of the calendar. After Christmas, the season of giving, comes Valentine’s and the season of love. Then comes the Lenten season, the typhoon season…and we’re back to Christmas again. But what might we gain if we don't take these things for granted? There are different perspectives that allow us to look at Valentine's - and other holidays - in deeper ways.

A political economy approach, for instance, would historicize Valentine's Day, from its beginnings as the Catholic “Feast of St. Valentine” into its present form, and examine how institutions, including industries, have played a role in shaping it. In Japan, for instance, it was large businesses that fostered the tradition of girls giving boys chocolates on Valentine’s Day, and in 1978, Japan’s National Confectionery Industry Association launched the tradition of boys giving back - chocolates of course - on “White Day” (March 14) - month after Valentine’s.

Gender studies would look at how Valentine's Day serves to perpetuate ideologies of gender, that is, societal expectations of what it means to be a man and a woman. In Valentine’s Day “rituals”, the male is the gallant giver while the female the gracious receiver. The “ladies’ man” knows how to make his woman (or women) happy, and the women are expected at their most beautiful.

On the other hand, public health would look at more pragmatic concerns, such as the proliferation of sexually-transmitted illnesses. Some years ago, the Department of Health distributed condoms during Valentine’s Day, which provoked objections from the Catholic Church. Just a few days ago, Secretary Garin encouraged condom use, invoking the rising cases of HIV to give her appeal a sense of urgency. We think of love as the province of emotions and feelings but the blurred lines between love and sex implicate the body - and the biomedical - in thinking about romance.

What can we take from these perspectives?

First, holidays can be problematic, even oppressive, to people who do not have the means to celebrate them in a culturally sanctioned way. The images of Valentine's Day come with a price: the (overpriced) roses, the chocolates, the dinners, and this could be a burden especially to the poor. Will Choc-Nut suffice - or sampaguitas? Our Valentine’s rituals are embedded in a value system that gives preferences and hierarchies to certain categories of things, such as imported chocolates, and particular kinds of flowers.

The gender ideologies at play can cause singles to feel left out, and so might gays and lesbians, as well as those who have lost their loves, for whatever reason. Arguably, in making “couples” visible, Valentine’s Day creates “singleness” as a category that many people may not even think of during the rest of the year.

Second, however, holidays are amenable to change, contestation and resistance. Writing for Time Magazine (Feb 11, 2015), Janice Kaplan spoke of celebrating Valentine's the day after - when the prices of roses are much cheaper, the restaurants quieter. “Love always seems lovelier to me at half-price the next day,” she quips. Others reject the perceived materialism of Valentine’s by exchanging gifts that cannot be bought: singing a song, making a poem or a letter, or preparing dinner for their loved ones. These acts remind us that “commercialisation” merely furnishes us with symbols whose meanings still derive from the relationships themselves - and challenges us to be creative.

Moreover, people do appropriate Valentine's Day to fit their own circumstances and identities. Single people gather together in parties or even “group dates” to celebrate their “singleness”. In modern societies where marriage rates are falling, and where staying single is a growing preference, magazines now trumpet the benefits of being single in Valentine’s while others offer ways to celebrate it as a single person (Huffington Post suggests “Have a great time with friends”). Still others emphasise a celebration of love construed more broadly: for our family, friends, and beyond. For instance, WWF-Philippines, on their Facebook page, exhorts people to “have a big green heart for the planet."

***

Today I passed through EDSA and the billboards, too, pay tribute to Valentine's Day. There are romantic jazz concerts, dining promos in hotels, and invitations to “be beautiful” in this month of love. Even the red SMDC logo of a rising condominium near Shaw was laced with hearts.

But for all our thinking and theorising on what all these means, I suppose that in the final analysis, what would matter more to us is still what would bring the most joy to our loved ones. For someone who expects a bouquet of flowers, a poem might not suffice, unless you agree beforehand that it's a great idea. Thinking about these things, thus, requires thinking together - a call that can be extended to our society at large. One place to start is the mindfulness that there are many ways to celebrate - or not to celebrate - Valentine's Day. Just as there are many ways to love, and many ways to celebrate love.

Manila
February 12, 2015

Three parents, one baby

by Gideon Lasco, MD

This week's medical headline is the British parliament’s decision to allow “three-parent babies” - babies conceived through in-vitro fertilisation with the genetic material from three different persons.

The fine print is far less dramatic. The intent of the law is to help treat diseases of the mitochondria, the “powerhouse” of the human cell, which is estimated to affect 1 in 4000 babies. By replacing the mitochondrial DNA, any disease that the parents have will not be passed on to the baby. The mitochondria actually has its own mode of inheritance, and researchers say that replacing its DNA will not affect any traits of the body. In fact, they say that the “third parent” - a female donor - will only contribute 0.01% of the baby’s total DNA.

These assurances, however, have not stopped various sectors, including religious groups, from opposing the move. Others have raised their fears that this law can open a Pandora’s box of eugenics, leading to “designer babies”: the idea that a baby’s genetic make-up can be designed i.e. to have blue eyes, tall stature, and the intelligence of Albert Einstein.

Part of the newsworthiness of the story draws from the fact that we are used to two-parent babies: an egg and a sperm combining to form a zygote which then becomes a baby.

***

The idea that there can be more than two biological parents, however, has been around in some cultures around the world. The classic example is that of some tribes in Tibet, where people practiced fraternal polyandry, or brothers sharing a single wife. Scholars eventually found 53 more societies where polyandrous unions were allowed. Unlike our biological sperm-meets-egg “explanatory model” for having a baby, in some cultures it believed that a baby is formed by the accumulation of sperm through repeated intercourse, a belief that anthropologist Stephen Beckerman calls “partible paternity”. Thus, the different men who were all husbands to the same wife were seen as all fathers of her offspring, regardless of the actual “father”.

What makes the "three-parent babies" law radical is that in provides scientific certainty of having three parents in the biological (i.e. genetic) sense, which runs counter to our way of conceptualising biological parenthood.  Anthropologist Mary Douglas once theorised that taboos come from violations of culturally-held systems of classification. Her theories remain relevant in our age of genetics: the idea of three parents contributing to a single progeny is repulsive because babies would be seen as “taxonomic anomalies”; they violate our way of looking at persons as having, in the biological sense, a single mother and a single father.

On the other hand, supporters argue that people should not let their prejudices get in the way of life-saving treatment. They point to organ transplants, fairly routine in the West, as examples of people having different DNA material in their body. As for fears that this will lead to “designer babies”, even supporters are divided. How far can technology go?

***

As we observe developments like this from the Philippines, we need not do so with the fear or expectation that they are “coming soon” in the country. There is more than one road to progress but looking at different cultures and the changes that are unfold among them allows us to look at our own with deeper insight - and with a more open mind.

One important insight from the British law is that we can never separate the biological from the social. Notwithstanding the mere 0.01% genetic material that would come from the donor, it is enough to make her be seen in the popular imagination as a “third parent”. Would the future baby be allowed to get to know his or her third parent? How would their dynamics be like? In the US, some laws disallow organ transplant recipients from getting in touch with their donors or their donors’ family, but medical anthropologist Margaret Lock demonstrated that despite this, recipients do yearn for connections with donors’ families, and some organ recipients feel the personality of the donor shaping their own, even though there is no “scientific” reason for that to happen - a case of what Lock terms “local biologies”.

In the Philippines, while we do not have "third parents” in the biological sense, we often speak of parents other than our official ones. An example would be cases where paternity is in doubt. Also, in our age of overseas work, we find not just fathers becoming “mothers”, but grandparents becoming parents to their grandchildren. Of course, adopted children have two sets of parents, and while they may yearn to know their biological ones - a recurrent theme in our telenovelas - surely their bonds with their adoptive parents are no less strong than those of non-adopted children with their biological ones, even with no DNA between them.

Perhaps before we consider the ramifications of three-parent babies, we need to firstly contemplate on what parenthood is all about.

Quezon City
February 5, 2015

Pills, potency and fertility: The illicit trade of male sexual enhancement products in Quiapo, Manila

by Gideon Lasco, MD

In a paradoxical and very graphic juxtaposition of the sacred and the profane, the Minor Basilica of the Black Nazarene in Quiapo, Manila – popularly known as the Quiapo Church – is surrounded by peddlers selling all sorts of products, many of which act as 'pharmaceuticals', in the sense that they are invested with notions of efficacy and potency in effecting cures and enhancing bodies. Given its “medical” function, anthropologist Michael Tan has aptly christened it the “Quiapo Medical Center” (Tan, 2009). He emphasizes the temporal dimension in his lectures about Quiapo, saying that “it changes every time.” (personal correspondence).  

Considering its reputation for selling products that are outside the sanction of the law, the church, and the medical establishment, I decided to focus on enhancers or male potency and fertility, which is one such gray area. I, together with my research assistant Ryan Tuiza, visited Quiapo several times from August to September 2012 to identify which products are sold for male sexual enhancement, to describe how they are sold, and to whom. I was also interested in how the vendors describe their products. 

Ideally, we ought to have embarked on survey of which products are sold for sexual enhancement across genders (heterosexual males and females, homosexual males and females). However, we were limited by our own genders, which, as we found, made it difficult to relate to products that were not deemed appropriate for our use. Moreover, as we observed during our field work, the Quiapo vendors are very suspicious of the people who pass by, even as they offer their merchandise with spiels such as:



Para saan po? (For what?)
Ano ang hanap nyo? (What are you looking for?) 

The first question is interesting because it invites an answer based on the [pampa + x form], which denotes function. e.g. pampaalis ng lagnat (Remover of fever), pampalaki (Enlarger). After the initial visits, we decided to come up with our own opening spiels: 

“Naghahanap po ako ng pampagana sa sex...” (I'm looking for a mood-enhancer for sex..."“May pampa-buntis po ba kayo?” (Do you have something to make someone pregnant?)

These two spiels also reflect the two categories of substances we were looking for, enhancers of potency, and enhancers of fertility. In this short note, I will describe several products that are used for these purposes. Later on, I will continue to reflect more on our Quiapo experiences by offering thematic insights. 

ENHANCERS OF POTENCY

In this category, I use the colloquial usage of the term potency, i.e. male sexual performance. In the context of Quiapo, the attributes of potency – which are also seen as effects of the products – including “harder” and “longer” penile erections, greater physical stamina during sex, and faster “recovery time”. 

1. “Peter Cream” – This white cream from China is said to be a very potent enhancer of sexual performance. The container of the cream is illustrated with Chinese characters, with only “Peter Cream” in Latin letters. We do not know whether the naming of this product has something to do with 'peter' being a slang term for penis in countries like the United States. The effect is described in vivid detail:

Kapag pinahid mo yan, titigas agad yung ari mo. Makakaramdam ka ng kakaibang init... tatagal ka ng tatlong oras, at kahit 5 rounds kayang-kaya. Maaawa ka sa babae. (If you apply it, your penis will become erect. You will feel a strange heat. You will last for three hours, and even 5 rounds is easy. You will pity the woman.)

The peddler is so confident about its efficacy that he even invited us to try it to feel the effect. He adds that he himself uses it, and so does his old uncle. “This is popular with the old men,” he says.

The cream is applied just once, and the effect should be experienced within five minutes. For maximal effect, it is advised that the man takes a shower first before he uses it. 

Peter Cream is sold in different quantities, with ¼ of a container selling for P200, and the whole for P500. 

2. “Five in One” - This tablet is said to combine five different types of desire-enhancers (“pampagana”). Like Peter Cream, it also produces body heat (“nag-iinit ang katawan”) and the effect is seen after five minutes. For maximal effect, the stomach must be full before this is taken. 

Also, testimonials were invoked when the vendors try to sell this product. Depending on the number of tablets, it is sold for PHP 300 -500. 

3. Lana ng ahas (Snake's oil) – This is a panacea that is being offered more openly by the vendors: it is said to cure a myriad of conditions, from “anemic” to rheumatisms. According to one vendor, having it massaged on your body will stimulate heat (i.e. pampainit) which is also a form of sexual stimulation (i.e. pampagana), and is effective for both men and women. 

4. Dugo ng cobra (Cobra's blood) – This is a kind of snake wine allegedly with the blood of cobra on it, and is also said to enhance sexual performance, among other aspects of masculinity (i.e. pampalakas sa trabaho, energy-booster at work). Placed in recycled bottles of Tanduay rhum and other local liquor, you can see the body of the snake inside the bottle, and the liquid is amber-colored. Other bottles have the added ingredient of ginseng, which is also a known Oriental aphrodisiac. It is to be drank an hour before sexual intercourse to have full effect. 

5. Viagra (Sildenafil) – According to at least one vendor, Viagra tablets are also “available”, and interested buyers are asked to wait for 30 minutes. This was picked up by my research assistant, but unfortunately, we were not able to pursue this lead. There is also no way of ascertaining whether the alleged 'Viagra' tablets are authentic. Nevertheless, even with incomplete data, I am including it here for its mere existence is a significant finding.

To recap our rundown of enhancers of Peter Cream and “Five-in-One” seemed to be the most popular options, and are offered by several vendors, but these products are hidden from view, and are covered with manila paper. The herbals, on the other hand, and the oil and wine bottles, are displayed prominently along with amulets, candles, and sachets of leaves. Western medicines, represented in our survey by Viagra, may also be more available than previously thought. 

ENHANCERS OF FERTILITY

In this section, fertility is used in its biological sense, that is, the “natural capability to produce offspring”. We found that there are also products in Quiapo that are being sold for this specific purpose:

1.”Root crops” - This is a liquid concoction sold in bottles, and is said to be made of roots, bark that were mixed with vitamins which serve to “revive the sperm cells”. The vendors say it is made in China. 
It is said to have an effect as soon as one week, and should be taken thrice a day before eating.

According to one vendor, many people have already tried it, and they can attest to its efficacy. He told the story of a couple who failed to conceive after five years of conjugal union. They tried all sorts of cures, but in vain, until the husband started using the root crops. In just two months, the woman got pregnant. 


However, this special liquid formula comes with a steep price: P500 for a small bottle (around 50 mL) and P1000 for a bigger one (100 mL).

2. Vitamix tablet – Other vendors offer “Vitamix Plus” as a cure for infertility. It is to be taken twice or thrice a day before meals, and takes two weeks to a month to take effect. There are no contraindications to its use, and it is sold for P1000-P1500 per blister pack.

Unlike the other products, this one was amenable to further inquiry by searching for “Vitamix” in the Internet. Curiously, although the vendors say it is made in China, the online search identifies its source as an Indian pharmaceutical firm. 

INSIGHTS 

1. The eclecticism of Quiapo – I was honestly expecting to see indigenous and traditional products to come up – the traditional expectation of Quiapo – but a majority of the products we saw were ascribed to China, although we also saw that this does not necessarily mean that the true source is China. Regardless of the origin of these products, however, there are regulatory implications of this trend. More so when 'Viagra' comes up as one of the consumer choices. Three different medical systems are represented in Quiapo: Chinese, Western, and Filipino traditional, and seemingly, all are beyond the reach of regulation.

2. A vast referral system. To follow Prof. Tan's language, “Quiapo Medical Center” is a 'tertiary hospital' with a vast network of specialists, which ironically leads back to the medical profession. The offer of a referral to a doctor, coming from a Quiapo peddler, is demonstrative of the complicity of at least some health professionals. My research assistant also recalls being offered pamparegla in case his girlfriend needs it, hinting at other services: 

May malalapitan tayo ng tulong kung kailangan nyo ng pampalaglag...
(“There are people we can ask for help if you need an abortifacient”)

3. Suspicion and surveillance. Perhaps as an adaptation to the efforts to curb the trade of illicit products, the vendors are visibly suspicious of passersby, and even those who claim to be looking for products. Personally, I felt that I was not able to fully act out the role of a “typical” customer looking for sexual enhancement, or a cure for infertility – hence my strategy of getting a field worker. As if to affirm the existence of the illicit trade, banners surround the Quiapo church warning the public that the trade of abortifacients like Cytotec will be dealt with severely (Postrado, 2009). However, even when these government moves are met with success, there are many other products out there that require regulation and control. 

4. The power of testimonials. To boost their case for their products, vendors usually invoke supposed testimonies of their past customers. The image of an old man, does a lot to boost their case, particularly in the absence of any objective parameter to evaluate the products. Pit against the “evidence-based” medicine of health professionals are the “anecdote-based” medicine of the vendors, which actually appeal more to the public.

CONCLUSION

There exists in “Quiapo Medical Center” a market for products that promise to enhance male potency and fertility. Sold at relatively high prices, these products likewise suggest that there is a substantial the number of people who are willing to buy them, and vendors are quick to offer connections to medical practitioners, suggesting that the "biomedical sector" and the "informal sector" of health care not parallel systems; there are links between them.

With little or no product information, it is not just efficacy, but safety, that is a major concern as far as these products are concerned. Viagra was initially a drug for pulmonary hypertension until  male study volunteers discovered its "desirable" side effect. But this goes to show that these products have systemic effects that can very well be harmful to its users, especially the elderly who are often the target of these drugs. Health authorities should take this matter seriously.  

Made in China, banned in the Philippines, and sold without regulation, these products reinforce the view that “you can buy anything in Quiapo.” If its vendors are to be believed, the price of pleasure ranges from 200 to 500 pesos, “satisfaction guaranteed”. 

Manila

September 2012

REFERENCES

Tan, Michael. “Quiapo Oracle”, opinion article, Philippine Daily Inquirer, January 1, 2009. Available at: http://opinion.inquirer.net/inquireropinion/columns/view/20090109-182286/Quiapo-oracle

Chua, Philip. “Is street Viagra safe?”, opinion article, Cebu Daily News, January 19, 2009. Available: http://globalnation.inquirer.net/cebudailynews/opinion/view/20090119-184254/Is-street-Viagra-safe

Postrado, Leonard. “Quiapo vendors warned anew”, news article, Manila Bulletin, August 15, 2009. Available: http://www.mb.com.ph/articles/216062/quiapo-vendors-warned-anew