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Pinoy Kasi
Pain talk

By Michael Tan
Philippine Daily Inquirer
First Posted 00:37:00 01/29/2010

Filed Under: Culture (general), Medicines, Healthcare Providers

I WAS ASKED TO GIVE THE KEYNOTE ADDRESS AT THE UP College of Medicine?s 17th Grand Scientific Symposium with ?Pain? as their theme. I thought the topic would be of interest to my readers as well, so let me share a modified and very much abridged version of my speech:

Pain is important, a sign that something is wrong in the body. So cardinal a symptom is pain that in all Philippine languages, sakit means both pain and sickness.

Pain may be a biological sensation, but even as a sensation it often defies linguistic description because it is so subjective. It becomes even more complicated if we talk about pain behavior, which is the sensation itself plus the responses it elicits.

Health care providers need to understand pain behavior for three reasons. First, pain is an important?some will even say the most important?symptom, a guide to diagnosing illness, depending on the site and type of pain.

The difficult part is asking the patient to describe the pain. The health care provider will sometimes try to get the patient to quantify the pain. Older doctors tell me they used to ask, ?If you had one peso, how many centavos is the pain?? Apparently, pain has been subjected to inflation; these days, doctors ask, ?If you had one hundred pesos? or even ?If I you had one thousand pesos. . .?

Secondly, health care providers need a vocabulary of pain not just for diagnosis but to prepare patients for medical procedures. That?s easy with an injection, comparing the pain to an ant bite. Labor pain, on the other hand, defies description.

Finally, we should not forget that shared understandings about pain can become powerful tools for therapy. More than taking the right analgesic (pain-killer), a ?dialogue? around pain is just as important. That includes expressing the pain, verbally or non-verbally, and eliciting a response from people around us.

?Aray,? ouch

Let?s look more closely at the relationship of culture to pain. Pain behavior is defined and taught by society. Infants in pain will have similar crying, regardless of the culture they were born into. With time though, children pick up the social rules around pain: when to express the pain, even how to express it. I have seen young children learning to say ?aray? and giving up that word for ?ouch? (or ?ouchie? in the case of one of my kids) after entering an exclusive private school. I shudder to think of the words they?ll pick up as adolescents to express pain.

Problems in pain management come about when upper-class Filipino health professionals are unfamiliar with the local terms used to describe different kinds of pain. Anthropologist Felipe Jocano?s ?Folk Medicine in a Philippine Municipality,? first published in 1971, has a chart showing how the terms for pain vary depending on where it is and its sensation. Kirot in the muscles, for example, is more of a throbbing pain, while in the abdomen, it is more of a deep ?squeezing? sensation. Antak, on the other hand, is a sharp pain when in the muscles or the abdomen but when used to describe a headache, it can have a dizzying sensation, or it can be ?deep and full.?

Different social and cultural variables will converge to create differences in pain behavior. My parents are always commenting about how sparse the tears are during Filipino wakes and funerals, especially compared to the almost performed pain and grief of the Chinese, complete with hired professional mourners (and portrayed in the movie ?Crying Ladies?). But I have to remind them that what they see are upper-class funerals, which are almost Western in the subdued grieving. Being upper class means reining in the emotions and keeping pain private. In contrast, with low-income Filipinos, pain must be expressed as loudly as possible, even sometimes accompanied by self-inflicted pain.

Compare too the private and public obstetric wards. True, the rich are given epidurals more quickly, but even without the anesthesia, an upper-class Filipina will be a bit more restrained about screaming out, or screaming obscenities at her husband or domestic partner for getting her pregnant.

There are even gender differences in pain behavior. For example, Filipino men (and men in most other cultures) are actually privileged with pain, allowed to complain even for a headache. Women, in contrast, will ?hoard? pain, always worried about inconveniencing other members of the family. Suspecting an illness behind the pain, women worry more about additional expenses.

Paradoxically, while men whine much more with pain, they are also expected to look for pain as part of religious experiences. We see that in the Nazarene processions every January, and in the Holy Week crucifixions and self-flagellation. It may go back to a pre-colonial warrior culture where men had to prove their masculinity by withstanding pain. Add on Christianity with its emphasis on the redeeming power of Jesus? suffering. A book just published in Italy by Bishop Slawomir Oder says that the late John Paul II regularly practiced self-flagellation, as a way of penitence and imitating Christ. The book?s title, ?Why He is a Saint,? speaks volumes about how pain is perceived by many Catholics.

We see then that pain takes many culture-specific meanings, so the expression of pain might be seen as weakness or, for others, as an admission of wrongdoing (and thus being punished through painful illnesses). Others might see the pain itself as a way of atonement, a sacrifice.

In a medical consultation, a health care provider should assure the patient that they are neutral, that the patient can and should speak about his or her pain, including sakit ng loob (inner pains). A good health care provider understands the words and non-verbal body language that is used. A wise health care provider also ?hears? hidden messages in a patient?s description of pain: child abuse, domestic violence, even lingering stress from war, disasters, torture.

Cultural strategies

The vocabulary of pain is not just to describe the sensation but to comfort and to heal, and that?s where we often find ourselves at a loss. ?I?m sorry,? we would say in English to comfort a person in emotional pain, but that might be inappropriate in Filipino. ?Konting tiis lang,? we say, falling back on our culture of sacrifice and forbearance.

We also need as well to look at how cultures have evolved strategies to deal with pain. In the Philippines, we tend to be cathartic, even hysterical, which can be useful but sometimes becomes counter-productive. We need to explore and encourage more quiet forms of dealing with pain: touching, massage, even plain pain talk. Sometimes, too, we just need to be with a person in pain, our silent presence more powerful than any drug.

Other cultures have developed tools we can borrow. Western medicine is now looking into how Buddhist meditation might help: this means helping people to reduce pain by becoming more mindful of that pain, coming and going. I have seen it work wonders in patients with the most painful of diseases.

With more cultural tools integrated into medicine, health care providers and caregivers will become ?masters of analgesia,? overcoming sakit as pain and as illness.

* * *

Email: mtan@inquirer.com.ph

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