After three decades of medical practice in Baltimore Maryland, USA, I returned to my hometown, Tiaong, Quezon, and held residence in barangay Lumingon, atop a little peak called Pulang Lupa, in a place that became known as the White House. I came tagged with the trimmings of gentry—firstly, apo ni Doña Concha and landowner, then, to boot, a doctor, stateside at that, and therefore, rich. Thus, in that social setting, my life was defined. There were days when I would wake up to find the kubo filled up with people waiting for audience with me—asking for a loan, a scholarship, help for a burial or a casket, looking for employment, selling a cow, pawning a gun, or consulting on a medical problem. Slowly, over the years, it was the medicine that gelled into my primary role—medicine that would be continuously challenged by the alternative health care modalities of rural Tiaong: the albularyos and the hilots, the creatures of mythology and the folkloric credo that hold primary influence on their health care.

Of course, the reality that dictates health care choice in the rural area is chronic economic want. The majority of the rural population belong to the DE of the ABCDE socioeconomic classification—D with 60% share in number of families, 56% share in total income, with an average annual income of P191,000, and E with 30% SNF, 9% in STI, and P62,000 average annual income. It is the D and E that are the subject of boondock medicine. For all of the E (monthly income of 5,000 or less) and many in the D class (15,000/month), with the average of 5 members per family, the choice of whether to buy 2 kilos of rice and fish for table or to consult a doctor for a malady, which would cost 300 to 500 pesos—prescription cost not included—is a no-brainer. It is money better spent for more mundane necessities. This is a segment of the population where preventive health care doesn't exist— many passing through middle age without ever having splurged on a doctor's visit, an xray, or laboratory testing; for females, never a mammogram or a pap's smear. Besides, there is the albularyo or the hilot, whose consult and treatment can cost as little as P50. But before the albularyo, there is the popular and affordable practice of self-medication.

Self-Medication
For many, medical care isn't an affordable luxury. There are no rainy day savings. There's not much left from the day's wage or weekly budget for unexpected illnesses that visit. There is a list of illnesses that is managed by self-medication —including the medicating of a family member—without consultation with a doctor or albularyo, using over-the-counter medicines and prescription pharmaceuticals (easily bought from the boticas without prescription), and drawing from personal experiences or from a collection of rural medical knowledge from relatives, neighbors or friends.

Herbal remedies, although declining in use, are still used in self-medication, alone or in combination with pharmaceuticals. Leaf decoctions and poultices are often resorted to for rashes, itches, and swellings.

Some of the maladies for self-medication include: headaches (paracetamol or various herbal leaves applied to the temple), fever (paracetamol or tylenol, observed from 1 to 4 days), diarrhea (1 to 2 days, treated with OTC medicines, fluid supplements, Gatoraid if affordable); imon-imon (hives, scrubbed with fisherman's net), and painful dental caries (dentist's visit delayed for incredible length of time, treated with paracetamol, antibiotics, various herbs, or juice extracted from coconut shell).

Time was, the favorite self-medication was "magasawang gamot"—literally, husband-and-wife medicine, a P10 two-tablet cellophane-packed combination of paracetamol, an analgesic/antipyretic, and amoxicillin, an antibiotic, conveniently available without a prescription from many sari-sari stores, used for a variety of illnesses and complaints: colds and coughs, flu-like syndromes (trangkaso) and various gastrointestinal diarrheal disorders. The use of 'magasawang gamot" has significantly declined, according to some sources, due to my educational campaign against it. However, many other antibiotics continue to be acquired without a prescription, based on a collective rural compendium on pharmaceutical use based on "what the doctor prescribed for her should work for me" or what worked before should work again or whatever is in popular use for UTI, coughs, skin infections, and diarrheal afflictions, or trying a course of antibiotics on one's self that the doctor used before.

Although self medication may have helped resolve some of this conditions, many simply would have resolved with tincture of time. Sometimes, sadly, there are occasions of the tragic and fatal outcomes—infectious or diarrheal afflictions that failed attempts at home treatment, the fate doomed with further delay of treatment because of a detour consultation with the albularyo or medico.

Albularyos, Hilots, Medicos, Faith Healers, and Other Specialists
When self-medication fails, a local healer is often consulted, usually because he is the less expensive option to the physician, usually fifty pesos, or whatever one can afford. For some, the affinity to local healers may have to do with the use of familiar religious elements—prayers in bulong and orasyon, and the frequent belief that they heal by mediation of the Holy Spirit or possession or influence by the Holy Mother. They are considered to have special expertise for dealing with many indigenous conditions outside the purview, ability, and comprehension of western-trained or urban-based physicians: bales or bati (na-bales, na-bati), na-duwende, na-nuno, na-tikbalang, na-kulam, na-danyuhan, na-sapian, and of course. . . pasma. They bring a familiar cast of mythological creatures into the causation of diseases—tikbalang, duwende (elves), earth dwellers (nuno-sa-punso) and asuwang—and suggest motley choices of indigenous treatments: bintusa, kudlit, tawas, bulong, orasyon.

In the hierarchy of healers and specialists in Philippine folk medicine, the albularyo may be referred to as the "general practitioner." His treatments often involve a mix of alternative therapies: decoctions or poultices of herbs (leaves, roots, stems, fruits or seeds), often with a bulong or orasyon, prayers in pig-latin, whispered or written on pieces of paper (tapal) and applied to the area of malady.

Although the albularyo is usually the "first call" for alternative therapies, there are a other specialists in alternative medicine: the hilot, the mangluluop, and the medico.

The hilot ministers to sprains and strains, resets simple dislocations and fractures, often without the use of xrays, alas, sometimes with permanent misalignments. He uses herbs, bulongs and orasyons to help facilitate healing. Members of religious factions, in particular, Iglesia ni Kristo and Iglesia ng Dios, generally avoid albularyos but sometimes use the hilots, but without the use of bulong or orasyon because of the prayer elements.

The mangluluop, together with the manghihila and mangtatawas, are the diagnosticians, some specialized in tawas, using various indigenous materials of leaves, shells, salt, candles, oil, and tawas, to determine the causes of the maladies. Resulting shapes from these concoctions usually provide diagnosis, often attributing them to creatures of rural mythology—duwende (elves), tikbalang, earth dwellers (nuno sa punso)—or to fringe folkloric conditions unique to the culture or region (kulam, pasma, bales or bati).

The medico is the most specialized of the rural healers, usually versed in all healing and diagnostic modalities, merging age-old folkloric systems with acupuncture, reflexology, and the pharmaceuticals (steroids, NSAIDS, and antibiotics) of western medicine. Alas, the pharmaceuticals are indiscriminately prescribed, accessed without prescriptions from provincial "boticas", dispensed without the usual warnings and precautions of adverse reactions and side effects.

Doctors
Of course, despite the unaffordable expense, rural folk still consult doctors—when self-medication, tincture of time, and local healers fail to resolve the complaints. Also, there are conditions not left to chance: convulsions, especially when associated with fever; vomiting blood; difficulty breathing, prolonged loss of consciousness, lacerations needing suturing, fever with rash or suspicion of dengue, abdominal pain that might be appendicitis, chest pains that might mean a heart attack.

Most other non-threatening maladies do not make it to the doctor. For many in the rural areas, a visit to the doctor means food taken away from the table, and for that reason, avoided unless absolutely necessary. When a visit to the doctor becomes necessary, the visits are too short and hurried, the prescriptions usually unaffordable, doomed to non-compliance—taken for two or three days instead of seven, once a day instead of three times a day, or half a tablet instead of one daily, or stopping it soon as one feels better.

Some diagnoses eventually make it to the provincial hospital or referred to Manila for evaluation and treatment. Alas, even when diagnosis is made and treatment advised, often it is not done because of cost. For many patient with cancer, it means returning back to the province, untreated or half-treated, unable to have the surgical procedure or continue the expensive chemotherapy, seeking affordable alternative therapies to prolong their lives, rather than sell their last few precious possessions.

Board Certified in the Boondocks
And in this milieu of superstitions and mythological creatures, of maladies cast by gnomes and elves, of spells, counter spells and possessions, where the local healers diagnose illnesses by the configurations of candles drippings, alum, embers, or eggs whites in oil or water, and dispense their folkloric treatments with concoctions of herbal roots, seeds, leaves and flowers, or fragments of paper inscribed with prayers in pig-Latin pasted on skin or stuck in bodily orifices . . . I dared practice my brand of Western medicine—board certified in the boondocks.

It took a few years to merge western medicine with alternative medicine—a merging that was facilitated by a foray into herbal medicinal plants and its ubiquitous use by the local healers. The education into alternative medicine was a surprising journey and appreciation of a cultural facet of a people—a fusion of superstitions, mythologies, and religion and the its influences on rural health credo. I was the avid student—observing healers and their treatments, extracting herbal healing stories from patients, and immersing into a study of medicinal plants. I saw the profound reliance of rural folk on alternative medicine for their health care needs—not just in the economics of it, but rather, for the ways they can relate to it: the hand-me-down folk healing, the prayers in orasyons and bulongs, the belief in the mediation by the Holy Spirit or Virgin Mary, and the many graspable elements of the various healing modalities.

Inevitably, my style of medicine was tested against the local healers. I was less expensive than the visit to the local or neighboring town doctors, even cheaper than the albularyo, meaning—free—gratis; to boot, free medicines when samples were available. But for the most part, it was a losing battle—my diagnosis, advice, and treatment often conflicted with the local healers, and alas, it was the latter that often prevailed.

Time and time again.

An elderly lady with new onset left sided arm and leg weakness, with a right carotid bruit on the left side of the neck, with moderately severe elevation of her systolic blood pressure clearly suggested a stroke syndrome. I'd bet the house on the diagnosis. I gave the family prescriptions/samples and instructions on bedside care and therapy. I did a follow up a week later to find out they have consulted an albularyo who diagnosed the condition as "pasmang ugat," reassured the family it wasn't a stroke, advised the family to stop the medications I gave, and prescribed herbs and an oily concoction for massage. As with many patients with stroke, there was improvement. Case lost: 1-0.

Another patient presented with week-old painful eruptions along sacral dermatomal typical of shingles (herpes zoster). I gave assurances the lesions would soon be disappearing and gave her samples of pain killers. I'd bet the house on the diagnosis. The following day, she consulted a medico who prescribed a course of dexamethasone (!) and a piece of burnt twig that she was suppose to pat on the lesions twice a day. She felt incredibly rejuvenated, of course, by the dexamethasone, the pain disappeared shortly after, the lesions gone in a week. Case lost: 2-0.

Breast tumors and cysts, bukol sa suso, are often taken to the albularyos, often attributed to dwendes and earthdwellers and hexes. Tapals, bulongs and orasyons are the usual treatments. Or, the husbands could be instructed to straddle their wife's chest and roll their testicles over the breasts. No matter how hard I try to explain that the role of hormonal fluctuation in the size of breast lumps, strories are told and retold of how effective the albularyo's treatments are.

There are many more such stories. I stopped keeping score long ago. If it was a game I'd have to admit I was being trashed in the competition. The hold of folk medicine on rural health care beliefs is profound and my attempts to deconstruct it have been futile.

Pasma is a favorite go-to diagnosis in adults, a malady unique in Filipino folk medicine, an amalgam of rural beliefs on cold-hot-interactions, accepted in many provinces and cultures, differing in regional variations and contributions of myth and superstition, but sharing in the belief it is brought about by exposure to 'cold' and water, in particular, showering or bathing after physical work, sexual intercourse, or too soon after childbirth, or ironing after washing clothes. The unhealthy coldness enters the body through skin pores, the vagina, the cervix and uterus, through other avenues of entry imagined by rural science, which with repetitive exposure eventually manifests as 'pasma' in any of various presentations depending on organ involved: Pasma (all diseases with tremors, pain, sweating, or swelling in the hands or feet), pasmang ugat (stroke, migraines, various headaches), pasmang bituka (upper abdominal pains, nausea, vomiting), pasmang matanda (arthritic complaints in the elderly). Many other complaints can be included in the pasma umbrella of diagnoses. Treatment is as varied, some way-out fringe: herbal decoctions, massage, bulong or orasyon. and even the use of one's own urine. The folk diagnosis enjoys the win-win benefits of tincture of time, acute complaints that would have resolved without treatment because of their self-limited nature, or for chronic complaints of established diseases, untreatable because they were brought too late to the attention of the healer.

Balis or bati is another favorite go-to diagnosis, especially in children, perhaps much more curious and bizarre as pasma. The diagnosis covers a wide range of complaints attributed to an admiring or complimentary greeting, for example: You look good today. Your hair looks nice. Or, the baby is so cute. The compliment carries "bad wind" that enters the yet weak and defenseless bodies of infants and young children, manifesting as nausea, vomiting, loss of appetite, flatulence, headache, or dizziness. The immediate verbal antidote is to say: Puwera usog. Treatment is as varied as it is bizarre: saliva from the person responsible for the compliment, and like pasma, herbs, bulong, orasyon, tapal, and to boot, a preventive accoutrement, the unton. Of course, the malady is self-limited and resolves with tincture of time, giving folk treatments seeming effectiveness.

I have long conceded the battle. Now, when patients request a consultation, I ask or insist that they first consult with the local healers. Now, I see mostly patients who failed the treatments of albularyos and medicos. Patients with diagnosed chronic medical conditions who can't afford doctor's visits and treatments. Terminally ill patients and patients wanting to die, mostly wanting relief of pain, some asking for the death pill—gamot nang kamatayan. There were never any death pills dispensed; instead, words of comfort and counsel, what is left of time for prayers, closure or forgiveness, or whatever else I can draw out from the medical bag of wisdom—a lingering touch, and sometimes, a few tablets of tylenol.

Families send word of gratitude. Sometimes, a visit, thanking me for taking the time to visit, to talk with their parent, for the "powerful" pills that allowed a patient to rest and sleep soundly in his last days.

In the boondocks, self-medication and local healers with their fringe therapies continue to reign supreme for day-to-day ailments. In the culture of poverty, preventive medicine and health maintenance are unaffordable, unimportant. And survive, they do, their immune systems fortified against indigenous maladies. Much of folk medicine works because of tincture of time—not because of the recitations of pig-Latin orasyon or bulong.

Sometimes, I wonder at the benefits of poverty for the older rural generation—who have escaped the new epidemic of obesity from fast food, sugars, and fat—with diets low in processed foods and meats, high on salted fish and sardines, diets rich in natural nutrients and antioxidants derived from whatever they can pull out of the grounds (leaves, roots, tubers) or picked from trees (papaya, banana, coconuts). They live as long or longer than their counterparts in the polluted big cities with their modern medicine and polypharmacy.

City doctors, knowing little or zilch about it, look at rural alternative medicine with disdain. Folk medicine is a fascinating window to the theater of Philippine rural culture, awash with elements of prayers, herbs, rituals, superstitions, and mythologies that contribute to their beliefs on health and healing. Most are unaware of the studies done on many medicinal plants, and the evidence that support their use in alternative medicine, and the potential of a true merging of traditional modalities with urban medicine. A basic knowledge should be compulsory for doctors, and for students of medicine, an in-depth curricular inclusion. It will help bridge the great disconnect between urban and rural alternative medicine.

by Dr Godofredo U. Stuart Jr.