Category Archives: medicine

Qwertyman No. 92: The Return of the Old Normal

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Qwertyman for Monday, May 6, 2024

FEW WILL remember it, but yesterday, May 5, marked the first anniversary of the official end of the Covid-19 pandemic as a global health emergency, as announced by the World Health Organization. Of course it didn’t mean that Covid was over and gone—it would continue to mutate into thankfully less lethal variants—but the worst was over. It had infected more than 765 million people around the world, and killed almost 7 million of them; in the Philippines, as of last month’s latest figures, over 4 million of us caught Covid, and we lost more than 66,000 friends, family members, and neighbors to the disease.

It’s amazing what a difference a year makes. The pandemic rules had been relaxed long before May 5 last year, and much of 2023 and 0f the present year had been spent by us trying to get back to life as we knew it pre-Covid at a frenetic pace—engaging in that new term, “revenge travel,” buying new cars, building new homes, and as of last week, complaining about the infernal heat wave like it was the worst thing to have plagued us in decades (maybe it was—since Covid). For the most part, we seem to have willed Covid out of our minds, eager to replace its bitter memories with fresh and happy ones—an entirely human thing to do, to cocoon ourselves against the pain of loss. Are we in the “new normal,” or have we returned to the old?

I remember most vividly the paranoia that gripped the country during the pandemic’s early days—the first reports of people we knew dying horrible deaths in isolation, the terror following a sudden and suspicious onset of coughing and fever, the constant fear of carrying the virus home to the innocent and the infirm in one’s shoes, one’s clothes, one’s merest touch, the rapid disappearance of disinfectants and bread from the shelves, the inevitable closure of cinemas and restaurants, the anxious eyes peering above face masks and through face shields, the physical boundaries beyond which only a select few could cross—and, of course, the near-endless wailing of sirens announcing the imminence of death and dying. Unfamiliar words and phrases entered our vocabulary: co-morbidities, social distancing, quarantine, lockdown, ECQ, EECQ, RT-PCR, community pantry, antigen, remdesivir, hydroxychloroquine, Ivermectin, Sinovac (and anti-vaxx), etc.

Like many others, I lost friends to Covid, from very early on when no one knew what was really going on and what could be done to save patients who were turning up feverish and could hardly breathe. One of them was my own cardiologist, who reportedly assisted a patient whom he didn’t know carried the virus. Others were academics and senior officials returning from conferences overseas. Fortunately, no one in our families died of the disease, although many of us, myself included, later caught it at some point despite all precautions. When I did catch it, I have to admit that it was with a strange sense of relief, not only because I could now count myself a participant in a grand if horrible experience, and also because I imagined, perhaps foolishly, that I would be rewarded with some kind of immunity from further and worse infection.

Those of us who survived Covid hopefully did so with a more profound appreciation of the gift and value of life, and of the need to do good in the time we have left. But the 2022 elections only seemed to prove the power of political patronage, which became even more keenly felt during the pandemic, when local officials down to the barangays held sway over their constituents like never before. Covid sharpened the already stark contrast between rich and poor, from access to what were seen as the most effective vaccines to self-declared exemptions from certain restrictions like liquor-lubricated parties and literal hobnobbing. In the end, the virus didn’t discriminate, scything rich and poor alike, although the poor, living in cramped communities, were always more likely to fall ill and die.

What the public often failed to witness—and therefore can’t remember—were the stories of the frontliners who met Covid head-on and served as heroes behind the scenes. I’m now working with Dr. Olympia Malanyaon—a pediatric cardiologist who also served as Director of the Information, Publication, and Public Affairs Office of UP Manila—on a book she’s writing to document the efforts of UPM and of the Philippine General Hospital (which is part of UPM) to respond to the Covid crisis. The PGH, the country’s largest public hospital, was designated a Covid-referral hospital almost as soon as the pandemic broke, and its people found themselves in the vortex of an unprecedented medical and social crisis, and we want to tell their stories in this forthcoming book.

The word “hero” gets bandied around a bit too easily these days, but if there was a time for heroes to emerge, it was during the pandemic, when what used to be the most routine decisions (“Should I report for work today?”) could mean a matter of life and death. When the death toll mounted, many PGH staff resigned for fear of infecting their families, but many more stayed on, with nurses pulling 16-hour shifts and some doctors remaining on duty for as long as 30 hours.

Even utility workers recalled how pitiful the plight of the afflicted was. One said that “They had no one with them, not even when they died. They would be put into body bags, which could not be opened. Then they would be cremated the next day, without being seen by their families.” And then, the staff felt shunned by society when they went home as ordinary neighbors. “When we ordered at the fastfood, the guard shooed us away when he learned that we worked in the Covid unit,” recalled another. “I was very upset. It felt very degrading to work so hard, to line up for food when you got hungry, only to be turned away.”

Thankfully, the crisis also brought out the best in some other Filipinos, such as those who poured their time and money into community pantries that served the hardest hit. For a while back there, we saw and felt the glimmer of our inner heroes. It was a spirit that I hoped would be sustained into a broader and more enduring wave of change in 2022, but as the pandemic receded, we realized how much of the old normal yet remained.

Covid made us aware of the precariousness of our health as individuals. Looking forward to 2025, I wonder what it will take for our people to value their well-being as a society and as a nation.

(Image from Reuters/Lisa Marie David)

Qwertyman No. 84: An Advocate for IBD

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Qwertyman for Monday, March 11, 2024

YOU’LL FORGIVE me this “proud papa” moment if I preface this week’s column with the news that our unica hija Demi Dalisay Ricario, who’s unbelievably turning 50 later this year, represented Asian-Americans—and indeed the Philippines—on Capitol Hill in Washington, DC recently to lobby for changes in US health laws on behalf of patients. That’s an ocean and a continent away and doesn’t really affect us, but what’s salient here is that Demi went there on behalf of the American Gastroenterological Association (AGA) as an advocate for Inflammatory Bowel Disease (IBD) concerns—and that touches on our lives as Filipinos.

IBD is one of those little-known and often misunderstood diseases that can turn life into a living hell for its sufferers. It comes in two variants—ulcerative colitis (UC) and the more severe Crohn’s disease (CD), both of them involving inflammation of parts or all of the intestines. Often accompanied by bloody diarrhea, UC and CD and can be extremely painful and be lifelong burdens—or even turn fatal. 

Their causes remain unknown, but genetics, environmental factors, and immune responses seem to be active factors. Remedies include strict dietary changes and employing colostomy bags. Patients can find their social lives diminished or even be stigmatized. It’s not that common—according to the IBD Club of the Philippines, UC hits 1.22 out of 100,000 Filipinos and CD just 0.35, but it’s that same obscurity that makes it difficult to recognize, diagnose, and treat properly. In our culture where people tend to ignore or diminish their ailments—especially embarrassing ones—and consult doctors only as a last resort, the problem gets magnified.

It was on one of our visits with Demi in San Diego ten years ago that she fell terribly ill with blood in her stool, and despite all the tools available to modern American medicine, no one could tell why. Only months later was she positively diagnosed with UC, bringing both relief and radical lifestyle changes, especially to her diet (she can’t eat anything with wheat like ordinary sliced bread, among others). She held a high-pressure job as a frontliner in one of San Diego’s premium hotels, and stress is a high inflammatory factor.

“People often struggle to understand that IBD is an invisible illness, which means that sufferers might look healthy outwardly yet still experience significant health challenges,” Demi says. “This misconception is particularly challenging for individuals like me, who worked in high-end environments like the US Grant hotel, where maintaining an elegant appearance and managing demanding clients was part of the job. The contrast between looking ‘well’ and feeling unwell led to misunderstandings, as people would say, ‘But you don’t look sick!’

“The unpredictability of IBD symptoms significantly impacts mental health and daily life (it makes me anxious sometimes). Fluctuating symptoms such as frequent restroom visits and pain can hinder social interactions and activities. The inconsistency of the disease makes it difficult to commit to plans, as fatigue is a common issue. Additionally, managing a career can be problematic; frequent medical appointments and unexpected flare-ups often disrupt regular work schedules. This was my experience at The Grant, where I had to forego managerial opportunities to avoid exacerbating my condition. Additionally, managing relationships and friendships can be complex with IBD.”

IBD patients have a hard time at parties and social events, especially in the Philippines, where pakikisama is part of a strong food culture. People with colitis can’t eat ordinary bread or drink milk (think halo-halo). Demi has had to be adept at declining offers of food—a no-no for Pinoys—and explaining her unusual condition.  

“Before heading to any event or restaurant, I take a look at the menu online to figure out what I can eat. I’ve even gotten into the habit of giving the host a heads-up about my diet to make sure there’s something on the table I can actually enjoy. When it’s time for those long flights to places like Manila, I pack a stash of gut-friendly snacks in my carry-on (usually gluten-free bread, granola bars, nuts, and fruit). Whenever available, I pre-order gluten-free meals for my flights. After dealing with IBD for almost a decade, I’ve learned the hard way what foods are my friends and which ones are foes, such as gluten and lactose.”

To help her fellow Pinoys deal with IBD, Demi created a “Dear Colitis” Facebook page, also to encourage them to come out in the open and realize that they have a virtual global support group. Her advocacy continues online and with various entities like Pfizer, the Academy for Continued Healthcare Learning, and the Crohn’s Colitis Philippines FB group. Last year she was invited by the American Gastroenterological Association to join six other advocates as part of their pilot Patient Influencer Program to help promote IBD awareness, giving her the opportunity to participate in this year’s Digestive Disease National Coalition Public Policy Forum in DC. 

She explains that “Filipinos dealing with IBD should be well-informed about their condition and discerning about the reliability of information sources they encounter. It’s crucial for patients to be their own advocates, boldly voicing their needs and concerns whether at home, in the workplace, or in social gatherings. This self-advocacy is key to maintaining a good quality of life. Cultural concepts such as hiya (shame or embarrassment), pakikisama (camaraderie or fitting in), and the fear of being a pabigat (burden) can pose significant challenges. These factors might discourage individuals from speaking out about their condition, but overcoming these barriers is essential for their well-being and mental health. By confidently communicating their needs and educating those around them, Filipino IBD patients can navigate their condition more effectively while fostering understanding and support in their respective circles.”

Spoken like, well, a spokesperson, but I think a good one for the job.

(Illustration from Johns Hopkins Medicine)

Qwertyman No. 73: Nurse and Patient Both

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Qwertyman for Monday, December 25, 2023

(Today I’m offering, as I customarily do, a Christmas story, albeit one in rather unusual circumstances, to provoke us into reflecting on what Christmas should mean.)

NURSE NESTOR couldn’t recall how many times he had performed this procedure—thousands, for sure, in the ten years he had been with the hospital—and he had to acknowledge that it did get easier with practice to the point that he could lecture newbies on the proper way of doing things, such as changing diapers based not on their availability but on the patient’s needs, to avoid prolonged wetness leading to contact dermatitis.

He had become largely inured to the smell of urine and excrement, and all the other effusions sick bodies produced. Some other nurses and doctors dealt with that by employing exotic methods like putting coffee grounds or some other odor absorber in the room or applying lavender oil under their noses, but double-masking was enough for him, until he understood that some smells were simply too powerful to be suppressed, and that a philosophical kind of acceptance was the only real way of surviving along with one’s patients. Soon he reveled in being able to undertake the toughest assignments, such as the aging movie star who refused to let people know that he had had a colostomy, even when the hole in his belly began to leak. They had chatted about his biggest hits as Nestor irrigated the stoma, flushing out the detritus, until the man was in tears, but not over the pain of the process. 

It would have been easy to say that Nestor was now on duty in the ICU because of his proven expertise, and that he could be proud of having been selected for this shift on Christmas Eve, but he knew none of it was true. He was there because everyone else had a family to hurry home to, and he did not. He lived in a rented room in San Marcelino, a short jeepney ride away from the hospital, and took his meals in a nearby restaurant that toted up his bills at the end of the month; he did not even need to tell them what he wanted for breakfast. They would be closed on Christmas morning, so he would have to reach into his cupboard for some noodles or sardines.

It would have been different if Celeste hadn’t gone off with that anesthesiologist in his Miata, just because Nestor was on overtime when she needed a ride home. They used to wait for each other in the cafeteria, watching YouTube videos or making silly Facebook posts. Months afterward, when her blistering affair with the doctor was over and he saw her in her old chair fiddling with her phone, he would have swallowed his pride and swept her back into his arms, but she looked away and he had to pretend to be interested in the lunch menu.

Nestor knew the minute he saw the boy—because that was just what he was, a boy in a tall man’s frame—that he was trouble. Half his head was swathed in bandages and a leg was encased in plaster, like he had stepped out of a Mr. Bean comedy with something explosively hilarious about to happen, but the boy stared at him with a vehemence Nestor did not think possible out of one good eye. Nestor read his chart and saw that Patient Philip V. had been involved in a car crash the day before and had broken some bones, but nothing too seriously; he was going to live. He had not been drinking, which was unusual. Nestor could see that Philip had wetted himself, which was also unusual, as most patients had a hard time pissing after surgery, for a variety of reasons. He wondered why Philip had not been catheterized—possibly the Christmas rush? 

“I’m wet,” said the boy in an angry slur. 

“I know,” said Nestor, lifting up the patient’s gown to verify what he could sniff. It was nothing.

“I’ve been buzzing you—someone, anyone—for minutes. Where the hell is everybody?”

“It’s Christmas. People go home. People stay home. What happened to you?” Nestor began putting on his gloves.

“What are you doing?”

“I’m cleaning you up. If you don’t mind, I’m going to wipe you front to back to minimize infection, examine you for rashes. Then I’ll put a diaper on you, unless you want a catheter—you know, a tube I’ll stick into you—”

“I know what a catheter is. I have a master’s degree, in something no one cares about. I look too young, right? People always tell me I’m too young for this and that.”

Nestor looked at the boy and the hollows of his cheeks, the pale skin that bruised too easily, the slender bones that spoke of homes with swimming pools and SUVs in the garage and colognes in the bathroom. He remembered Celeste’s beau, a mestizo Chinese who wasn’t even handsome but who, Celeste said, could play the piano. He saw the boy’s limp privates and wondered what damage they had done, and felt a welling contempt. He wanted to pull the sheet out from under Philip as roughly as he could and shove him against the bed’s railing until he screamed.

“Hey, you look annoyed,” said Philip. “I know what you’re thinking. It’s Christmas and you’re stuck here with me and my—whatever. Go ahead, take it out on me. Hurt me. I never asked for this,” he said, gesturing at the straps and tubes he was attached to.

“Shut up and let me work.” Outside the ICU he could hear the patter of feet and the squeak of a gurney being rolled down the corridor, at the end of which a string of colored lights blinked around the swing doors, surrounded by foamy patches of fake snow.

“How much worse can it get? My parents are flying in tomorrow and will pull me out of this, like they always do—” He felt Nestor grab his leg. “You can’t hurt me even if you wanted to. I tried to kill myself, did they tell you that? I crashed my car into a post, but—the post was lousy and gave way. Whoever built that made some money.” He let out a dry chuckle.

Nestor stopped, holding an immaculate diaper between his hands. “No. Why would you do that?”

“Because they wanted to keep me away—from—from Timmy. They didn’t need to. Timmy’s gone. He left ahead of me, a week ago. He was better at it than I was.”

There were ways, Nurse Nestor had sometimes thought, that patients falling under “Code Gray”—unruly, irrational, and combative persons—could be brought to heel, or even privately punished. Caregivers needed that certain leeway—a pinch here, a pull there—to express and to expel their innermost emotions. He looked at Philip, suddenly smaller and meeker in his hospital gown. He resolved to show him how an adult diaper could be put on with the least discomfort, to nurse and patient both.