Filipino pain

Did you know there’s a Pain Society of the Philippines, affiliated with an International Society for the Study of Pain? The members are specialists called algologists, from the Greek “algos,” which means pain.

I had heard about pain specialists but didn’t know they had an association of their own until they invited me to speak at a symposium they organized to mark the 20th anniversary of St. Luke’s Pain Management Center.

Dr. Lynn Rodrigo came to pick me up and on the way to the symposium, I was updated on their work, which crosses disciplines and specialties. They include neurologists, anesthesiologists and physicians working with chronic diseases that involve pain (rheumatism, for example).  At the symposium I got to meet Dr. Cenon Cruz, who brought this specialization to the Philippines. His opening talk was actually a history of algology in the country.

Pain management is crucial in medicine. Pathology, or the study of diseases, focuses on pathos, or suffering, and the core of suffering is pain, especially in the Philippines (and some parts of Indonesia and Malaysia), where sakit means both pain and illness.

Might this mean we’re more vulnerable to pain? Dr. Francis Javier, who until recently headed the Pain Management Center at St. Luke’s Medical Center, is looking into the genetics here, comparing Filipinos of mixed ancestries to see if there are differences in the way pain medicines are broken down in the body.

Culture plays an important role in the way we experience, and express, pain. Across cultures we have similar sounds in reacting to pain. Expressing pain is itself a way of coping, even making us feel better. Language provides us with additional ways to respond to the pain, a way to describe to others the pain (notice how in Tagalog we have so many words for pain—for example, kirot, antak, hilab and more).  Language allows us to seek comfort, or sometimes to blame someone for the pain (as women sometimes do when in labor, as when they scream at their husbands for getting them into maternity).

Filipino pathos and algos are shaped by two important forces: religion and feudalism. Christianity, Catholicism in particular, emphasizes pain as sacrifice. The panata, where we negotiate for a favor (including healing for oneself or a close relative), often involves an offer of pain, whether through a pilgrimage, participating in some rigorous religious observance such as the Nazarene devotions in January, or something more extreme like self-flagellation, or even crucifixion.

Redemptive pain

The physicians at the conference had stories to tell about this religious element, including patients who refuse to take their pain medications, or who on their own will reduce the dose, because they want to offer their pain. One physician even told me about a patient who rationalized that he had to endure pain in order to atone for a lot of sins (“maraming kasalanan”).  Individual pain is compared to Christ’s passion and suffering with its redemptive power.

Besides religion, feudalism also shapes our pain culture. Feudalism is a system of landlords and tenants, not the ones involving houses and apartments but of agricultural land and hacenderos. In a feudal system, the landlord controls the lives of the tenants from birth to death, sometimes even across generations. No matter how oppressive the conditions are, the tenants are usually loyal to the landlord because they see no other alternative for survival, and even consider themselves fortunate to be the landlord’s wards.

Feudalism has shaped the way we Filipinos think, so even if we are not tenants, we replicate a feudal culture especially in politics, where we are totally loyal even to officials who have plundered, simply because they are “mabait” with occasional handouts and gifts.

In a feudal culture we are required to beg for kindness. You see this among lower-end vendors—the child asking you to take pity on her and buy her sampaguita leis so she can go home, or the woman tiangge vendor asking you to buy because it’s late in the afternoon and she hasn’t sold anything.

A similar ethos operates in hospitals, with patients thinking they have to dramatize their condition so physicians and nurses will take pity on them and give them something to ease the ex-cru-ci-a-ting pain. “Find a way, please,” patients will beg in Filipino, punctuated by groans that often turn into wails.

It may seem that religion makes us understate pain while feudalism leads to “OA” (overacting), but in reality, there’s a lot of overlap. The idea of redemptive pain can also lead to drama because the more pain you project, the greater the sacrifice seems to be and the more pity elicited from those in power to reduce the pain.

Besides religion and feudalism, there will be differences across cultures in the Philippines. Although no research has been conducted yet, the algologists and I tended to agree that Ilokanos are more stoic than Tagalogs, and Tagalogs more so than the “Bisaya” who will also vary (I suspect Boholanos, for example, as being as Spartan as Ilokanos).

Gender also plays a role in the expression of pain, and again even without formal research, it seems men are quicker to whine than women. In part it’s biology, given how women have to go through labor pains, but culture also plays a role here. And ironically, the more macho and patriarchal a society is, the more men will feel entitled to complain and to demand instant relief from pain, while women will keep the pain to themselves, pagtitiis being raised to the level of a virtue.

Alternate culture

I did ask the Pain Society members to give more attention to nonphysical pain, the inner hurt that can be even more difficult than physical pain.  I’ve always felt that the mark of an experienced health professional (nurses in particular) is being able to hear a patient crying out “Masakit!” and knowing that much of the pain comes from weariness and loneliness.

Expressions of pain can also be ways of saying what can’t be said, the pain coming from sexual abuse, domestic violence, trauma from the past. The Pain Society, not surprisingly, also includes psychiatrists who are best able to deal with the “hidden scripts” behind pain.

We do need to help build an alternate culture of pain that goes beyond pity, starting with a broader “vocabulary of pain” that empowers patients. We tell children to be “brave” with injections and other medical procedures, and they do so because someone—Tatay or Nanay, Lolo or Lola—is around. Even if they do end up crying, we comfort them by emphasizing, “That’s OK, you were a brave little girl.”

Adults are more difficult because they need to unlearn all kinds of cultural scripts they’ve picked up around pain. Simple one-liners can go a long way, as a medical technologist at Cardinal Santos Memorial Hospital did while preparing to take blood from me: “Ang ganda ng veins mo,” a way of saying that blood extraction would be easy. I think I didn’t feel the pain because I was amused by the idea of veins being maganda (beautiful).

Seriously, the choice of words does make a difference. “Kaya mo ito” (You can bear it) is not very appropriate in a Philippine setting. Instead, use “Kaya natin ito” (We can handle this, together), as we hold someone’s hand. Empathy and solidarity are among the most powerful analgesics available.