This essay is reproduced here as it appeared in the print edition of the original Science for the People magazine. These web-formatted archives are preserved complete with typographical errors and available for reference and educational and activist use. Scanned PDFs of the back issues can be browsed by headline at the website for the 2014 SftP conference held at UMass-Amherst. For more information or to support the project, email sftp.publishing@gmail.com
The Philippines: Medical Industry Thrives, Health Care Fails
by Charles Dougherty
‘Science for the People’ Vol. 13, No. 2, March-April 1981, p. 16 — 21 & 33
Charles Dougherty has an M.S. in Agricultural Economics. He is a member of the National Phillipines Solidarity Network. He recently spent 6 months in the Phillipines. He works at the Pacific Studies Center, Mt. View, CA.
The health of a people is one of the best gauges of their overall economic and social well-being. The way in which a society deals with the problem of health reflects the broader social or class relations which prevail in that society. The poor health of the Filipino people is rooted in their profound poverty, which is generated and reinforced by the internal class structure and the extensive control of foreign (primarily U.S.-based) corporations over the local economy. As long as their martial-law government remains the faithful handmaiden of multinational corporations and local elites, the Filipino people will remain incapable of establishing a health care system which can solve their pressing health problems. A health care system which will benefit the majority of poor Filipinos can be constructed only by building a new set of class relations and a transformed state – one free from foreign and local elite domination.
The Link Between Poverty and Poor Health
Poverty is the overwhelming fact of life for the majority of the Filipino people. It stalks them from their cradles to their graves. Malnutrition, sub-standard housing, unsafe drinking water, and lack of access to sewage disposal are symptoms of poverty in the Philippines which directly affect the health of the poor. Eighty percent of pre-school children suffer from malnutrition. Forty-four percent of Filipinos have no access to sewerage, while over 60 percent lack safe drinking water.1 Millions of urban squatters live in ramshackle huts on stilts above streams of raw sewage in which the children frequently play.
Malnutrition, the seventh largest killer in the country, contributes to the high incidence of many fatal diseases. Despite their rich agricultural lands, Filipinos have the lowest per capita calorie intake of any Asian people, including Bangladeshis, Indians and lndonesians.2 In 1978, calorie consumption averaged 87.1 percent of the recommended daily allowance. Over two-thirds of families are too poor to purchase and consume a nutritionally adequate diet.3 Young children and pregnant and nursing women are hardest hit. In 1978, pregnant women received only 64 percent of the minimum calorie intake prescribed and nursing mothers only 46 percent.4 A 1978 survey reported that only 21 percent of the 5.1 million pre-schoolers surveyed were well-nourished. About 46 percent suffered from first-degree malnutrition, 26 percent from second-degree, and 7 percent from third-degree.5 Those who survive third-degree malnutrition usually suffer irreparable damage to their physical and mental development.
Pneumonia, often contracted by infants, kills one out of two of its victims in the Philippines. In 1975 it accounted for 16 percent of all deaths — the largest single cause. Gastro-enteritis and colitis together are responsible for about 6 percent of infant deaths.6 Altogether, 65 infants out of 1000 die before their first birthday, compared with 31 in Malaysia and 25 in Cuba.7 As many as 17 percent of all deaths are in the group aged one to four years, a figure nine times that of China and sixteen times that of Japan.8
Three-quarters of all children and pregnant women are anemic. Vitamin A and iodine deficiencies reach epidemic proportions in many areas. A study in Cebu City found 1 out of every 661 children under six was blind because of vitamin A deficiency. In epidemic regions, primarily mountainous areas, iodine deficiency is believed to have caused goiter in 60 percent of the children.9
Tuberculosis is the second largest killer in the Phillippines, accounting for 11 percent of all deaths in 1975.10 The Philippines has the highest rate of TB in the entire Western Pacific region, as well as the highest rates of schistosomiasis and polio. The Philippines also ranks among the highest in the world for its incidence of whooping cough, diphtheria and rabies.11 Many poor Filipinos also suffer from rheumatic heart illness, often a complication of untreated strep throat. Heart ailments are the third largest cause of death in the Philippines.12
The average Filipino lives only 59 years, compared with a life expectancy at birth of 70 years in China and 72 years in Cuba.13 Sixty-two percent of all Filipinos die without the benefit of medical attention.14
Bleak as this health picture is, available evidence suggests that it is growing bleaker, as the ordinary Filipino sinks deeper into poverty. The food intake of Filipinos has steadily decreased since 1958, a period during which real wages have also steadily declined.15 The worsening standard of living has had its greatest impact on nutritional levels since the declaration of martial law in 1972. Wages of industrial workers in Manila have declined by roughly 40 percent since 1972.16 The net incomes of rice farmers — the largest group of farmers in the Philippines — declined by 53.4 percent between 1976 and 1979 alone.17
Food intake, especially for low-income families, has declined significantly during this period. For families with annual incomes below P400 per capita (P7.56 = 1 U.S. dollar), calorie consumption between 1970 and 1974 declined from 87.5 to 79.5 percent of the minimum daily requirement over the same period. Daily protein consumption also declined substantially for all income groups during this period.18
Theoretically, the Philippine government could offset the effects of declining incomes on the people’s health by providing free or subsidized health care to the masses. It could place greater stress on prevention by improving the nutritional level of the population, upgrading the quality of housing available to the poor, and investing in more and better water and sewerage systems for both rural and urban households. Instead, the government perpetuates a health care system based on private gain, one which literally capitalizes on the poor health of the Filipino people.
A Terminally Ill Health Care System
The Philippine health care system is structured so that opportunities to provide an “ounce of prevention” are overlooked in the rush to provide a “pound of cure.” Such a system is irrational, since it costs less in the long run to prevent the most prevalent diseases than to continue treating them. Consider all the work hours lost due to illness and the lowered productivity resulting from malnutrition. One estimate of income lost as a result of malnutrition in the Philippines ran as high as U.S. $280 million a year.19
The Philippine health care system does have an underlying rationale: the search for profit. Since health is such a precious “commodity,” people’s demand for it is not greatly affected by the price of maintaining or restoring it. More and more Filipinos are unable to afford drugs, hospital fees, and even food. They are often confronted with a cruel choice: buying enough food for their families or buying the drugs needed to treat a tubercular father or mother. The sick family member may have to forego the medicine until it’s too late.20
The high prices of drugs are driving many Filipinos to their graves. Drug companies in the Philippines (especially the foreign-owned ones) subordinate people’s health needs to profits. Seventy percent of the local Philippine drug market is controlled by multinational corporations and other foreign companies. Overpricing of imports translates into higher drug prices paid by Filipino consumers. In 1972, Ampicillin derivatives marketed by Bristol and Beecham sold for about 25 cents per 500 milligram tablet; both firms are foreign-owned. In contrast, the Filipino-owned Doctor’s Pharmaceuticals’ brand sold for less than two-thirds that price.21 In 1979, 100 milligram tablets of Doxycycline were being sold by Terra Pharma (a Filipino firm) for two-thirds the price charged by Pfizer and Rachelle (both foreign-owned firms). These price differences mean higher profits for foreign drug firms than for their Filipino counterparts. While Metro Drug (a Filipino firm) earned roughly 4 percent on its assets in 1978 and Pharma (also Filipino-owned) earned merely 2 percent, Bristol was earning 9 percent, Pfizer was reaping a 12 percent return, Parke-Davis 15 percent, and WyethSuaco a whopping 19 percent.22
Foreign drug companies in the Philippines (as well as other Third World countries) market dangerous drugs which have been banned by regulatory agencies in their home countries. Some of the drugs which have been “dumped” on unwary Filipino consumers include the antibiotic Chloromycetin, a Parke-Davis product which is known to cause aplastic anemia; dipyrone and other pyrazolone compounds, analgesic/antipyretics which have been banned in developed countries; EnteroVisiform, an anti-diarrheal drug which contains cloquinol, proven to cause paralysis and eye injuries; Depo-Provera, an Upjohn injectable contraceptive never approved for use as a contraceptive by the U.S. Food and Drug Administration because of its link with cancer in test animals and a possible link with infertility and diabetes.23
Hospitals and other health care institutions are also part of the profit motivated health care industry. Since most paying customers reside in urban areas, hospitals are concentrated in the cities. While roughly two-thirds of the population live in rural areas, less than one-quarter of Filipino doctors practice in those areas. In Manila, the ratio of hospital beds to people is approximately 1 to 626 while in most provinces it averages 1 to 1400.24
Even within big cities like Manila, access to quality health care is far from evenly distributed. Of the 1420 hospitals in the country, almost eighty percent are privately-owned. Hospital administrators are accountable to shareholders who are often U.S.-trained doctors, who charge hefty fees in hospitals they partly own. The ordinary worker or squatter has no access to these institutions because of the prohibitive price.
Only twenty percent of the hospitals are government-owned; they must serve the majority of the population. Government institutions like Philippine General Hospital in Manila face serious problems of overcrowding and understaffing. In many cases poor patients are turned away for lack of space or personnel to treat them, even when their cases are critical. It is common for patients to die in the halls waiting to see a doctor.25
While most hospitals serve only those who can pay, they hardly pay those who serve. Wages of health care workers — especially nurses, who make up 60 percent of the health labor force — are kept at rock-bottom levels. In 1978 the median monthly wage of a ward nurse in the Metro Manila area was roughly U.S. $31.50. This is far from the U.S. $122 per month a single staff nurse requires to support him/herself.26 Many nurses are paid on an hourly basis, forcing them to work a 48-hour week just to make ends meet. Hospitals often squeeze in beds in excess of registered capacity, without hiring extra personnel to assume the additional workload. Physicians not in the upper echelon of U.S.-trained specialists fare little better than nurses. Government physicians, for example, receive a monthly minimum wage of roughly $70.27
The economic motivations of health professional training institutions complement those of hospitals. While the medical and nursing schools turn out as many graduates as possible to maintain their revenues, the flood of new medical and nursing graduates on the market each year guarantees a depressed price for medical labor. In 1978, forty-three percent of Philippine nurses who renewed their licenses to practice were not employed in their profession. Each year between fifteen and twenty thousand new nurses graduate from 140 schools and join the ranks of those looking for work in this buyers’ market.28 When nurses at Chinese General Hospital in Manila attempted to form a union in 1978, it was simple for the head administrator to fire the fifteen nurses, including the assistant head nurse, who were active in the organizing effort. Hospital administrators take the attitude, “there are plenty more where they come from.” Since many nursing schools are affiliated with hospitals, student nurses provide a large pool of free labor to the hospitals, paying high tuition fees for the privilege of working.29
While thousands of health professionals remain unemployed there is a crying need for more doctors and nurses, especially in rural areas. In Manila there is one physician for every 660 people, in Mindanao, the Bicol and the Eastern Visayas there is only one physician for every 5300 people.30 Roughly twenty-eight percent of employed nurses in the Philippines work in rural areas, where seventy percent of the population lives.31 Government rural health units are understaffed by about 23 percent in the case of physicians and 38 percent in the case of nurses.32 There is virtually no incentive to draw more doctors and nurses to the rural areas. The family of a newly licensed doctor invests approximately $10,000 in a son or daughter’s medical education, while the family of a nurse invests $5000. These expenditures leave most familes deeply in debt, so the new doctor or nurse is particularly pressed to find a remunerative job. To the extent that such jobs exist, they are not found in the hinterlands. Recent graduates often find no work in their professions, so that brothers and sisters must drop out of school to work to pay off family debts.33
It is small wonder that so many Filipino doctors, nurses and other health professionals seek jobs abroad. Since the mid-1960’s, American health care institutions have actively recruited Philippine medical graduates to solve serious understaffing problems. Those most frequently recruited for jobs in the U.S. (and increasingly in the Middle East) are the best-educated doctors, nurses, and medical technologists of each graduating class. Forty percent of all Philippine medical school graduates are practicing abroad.34 Ironically, in 1975 there were more Philippine medical graduates practicing in the U.S. than there were practicing Black American graduates.35 Of 5800 physicians recently interviewed in the Philippines, 70 percent said they planned to leave the country.36 More Filipino nurses are employed abroad than are employed in the Philippines. In 1978 there were roughly 16,000 active duty nurses in the Philippines compared with 20,000 Filipino nurses working overseas, 70 percent in the U.S.37 Four thousand more nurses left in 1979.38 The Philippine Ministry of Labor and Employment plays an active role in promoting the export of Filipino medical labor, demonstrating the low priority the government places on the health of its people. In 1979, the Marcos government spent approximately $15.74 per capita on the military while it spent only $3.72 per capita on health programs.39 In 1975 government expenditures amounted to 0.56 percent of the Philippine GNP, one of the lowest shares in the world.40 In 1975-76, The Ministry of Health devoted 70 percent of its total field operations expenditures to hospital services, which handle only 10 percent of all patients. The primary health care system, which focuses on prevention and handles 75 percent of patients, received only about 20 percent of Ministry of Health expenditures.41 Within the area of preventative health care, the government emphasizes family planning as the solution to the people’s health problems. This reflects the priorities of the major foreign aid programs which channel funds into the Philippine health care system. The U.S. Agency for International Development’s proposed aid package for the Philippines in fiscal year 1981 contains $14.7 million in grants and loans (26 percent of the total) earmarked for population planning; only $7.8 million is set aside for all other health programs.42 When government health officers assigned to rural health units organize clinics in the barrios (villages), these are usually family planning clinics. Evidence suggests that the Philippine government may have deliberately suspended its malaria control program in the early 1970’s in order to physically debilitate guerrilla movements in remote areas. Throughout the 1960’s malaria incidence had fallen dramatically, from 200 cases per 100,000 population in 1960 to only 85 per 100,000 in 1969.43 In the period from 1967 to 1977, however, malaria incidence increased fivefold.44 In 1973, U.S. A.I.D. phased out its support for malaria control, anticipating that the disease was well enough under control for the Philippine government to continue eradication measures with its own resources.45 Apparently, the government found better ways to use those resources. A Filipino military commander in Mindanao (an area of heavy fighting between government soldiers and Muslim guerrillas) admitted in 1973, “There is lots of malaria down there, so we have stopped spraying. Sooner or later the rebels will be too weak to fight.”46 It is probably more than coincidence that the malaria rate has escalated during precisely the same period when armed insurgency has been escalating throughout the Philippine countryside. The government has also tried to suppress rural support for the guerrillas of the Communist-led New People’s Army (NPA) through ploys such as civic action teams of the military distributing free medicine in “sensitive areas.” In many cases the military’s efforts have backfired. In Kalinga-Apayao the people refused offers of free medicines. In the Cagayan valley, the handouts were discontinued when the military began to suspect that the people were passing on the free medicine to the NPA fighters.47 When rural people who have never received any health care from the government suddenly find themselves the object of the government’s health concern, the hypocrisy of the government’s health programs becomes all too transparent. The people realize that the same soldier who is offering them medicine today is just as apt to shoot them tomorrow. Recognizing the credibility gap posed by “military healers,” the government has also assembled a civilian counterinsurgency force, into which all newly graduated doctors and nurses are conscripted before they can receive their licenses. Under the Rural Health Practice Program, new graduates are sent to the countryside for six to twelve months to work in provincial hospitals and rural health units. The government borrowed the concept from the Chinese “barefoot doctors” experience. However, the Philippine government tried to duplicate China’s program without comprehending the substance of it— the revolutionary transformation of class relations which laid the foundation for a new health care system in China. In the Philippines the profit-oriented health care system remains intact. The education doctors and nurses receive in the Philippines does not prepare them to work in rural areas. Their training is heavily oriented to American medical practices, with American textbooks the standard fare in most classes. When graduates leave for rural service, they are faced with an entirely unfamiliar setting. One nurse who worked in a squatter resettlement area outside Manila remarked, “In Carmona many people came to me with diseases I never heard of before.”48 These young medical workers also face the problem of a government which places a low priority on the program. Rural clinics are understaffed and poorly supplied. Rural service paychecks frequently are delayed by several months, if they arrive at all. A survey of 7900 doctors and nurses performing their rural service found that only 21 percent indicated any desire to continue working in the rural areas when their tour of duty was up.49 On the other hand, increasing numbers of doctors and nurses who have gone to the countryside under government auspices have become radicalized by their observation of conditions there and have joined the ranks of the resistance. Others, already politicized while in school, have taken the opportunity to conduct social investigation and propaganda work in remote areas. Perhaps realizing the program is becoming more of a liability than an asset, the government is planning to discontinue it.50 Health workers — of all professionals — are probably in the best position to observe close at hand the debilitating effects of poverty on the health of the Filipino people. They are also uniquely situated to perceive the inequities in the distribution of health care which mirror the inequities in the distribution of income and power in Philippine society. A growing number of these Filipino health workers have become convinced that only a thoroughgoing revolution aimed at a restructuring of the basic economic and political relations in their country and its liberation from the yoke of imperialist domination can provide a viable alternative health care system, one capable of responding to the most pressing health needs of the masses of poor Filipinos. A group of doctors, nurses, dentists, midwives, pharmacists, medical technicians, sanitary inspectors and others sharing this understanding came together in December, 1978, to form an organization known as Makabayang Samahang Pangkalusugan, or Nationalist Health Association. MASAPA, as it is called, drew up a seven-point program of action reflecting its commitment to participate in the national democratic revolution, which is currently gathering momentum in the islands and whose chief expression is the protracted people’s war being waged by the Communist-led New People’s Army (NPA) in the countryside. Following are excerpts from its program: 1. Combat the imperialist domination of the Philippine health industy. “The health sector should lead the campaign to dismantle foreign domination of the health system. This campaign calls for nothing less than the complete nationalization of the health industry … “… Self-reliance must be fostered as the foundation of a truly nationalist health system and industry. We must mobilize the broad masses of the people to take active part in the promotion of their health … “…Indigenous health knowledge and practices must be developed and elevated to the level of science …. We can develop a health system enriched by foreign scientific advancement but effectively free from imperialist exploitation.” 2. Oppose the use of health as a tool of the U.S.- Marcos fascist dictatorship. “The Marcos regime must be stripped of all its pretenses and the duplicity of its health care system laid bare before the people … “We must painstakingly conduct ongoing investigation of all government health programs, especially those with direct imperialist support and those involving military participation …. “We should build a broad alliance with anti-fascist service-oriented individuals and agencies and reorient their health services towards genuine mass-based, if not revolutionary programs.” 3. Development health programs to strengthen the revolutionary mass movement in the urban centers and the countryside. “In the countryside, we must earnestly respond to the serious dearth of health services catering to the needs of the rural population, and encourage the biggest possible number of health workers to render direct services among the peasantry. “Health programs … must go hand in hand with the effort of building basic mass organizations of peasants, youth, women, children and cultural activists in the barrios (villages). “In the cities, where health services and facilities abound only for the privileged, we should direct our health programs at the masses of workers and the urban poor, who make up the most numerous and most oppressed segment of the urban population.” 4. Gather the most extensive support of the health sector for the armed struggle. “We maintain that only by seizing political power and thoroughly restructuring society can we uproot the poverty and health problem of the masses. Only then, too, can we completely build a truly national and democratic health system. “It is, therefore, a paramount task of the health sector to support the armed struggle to its fullest capacity … The need for optimum health care among the people’s army and the revolutionary masses in the countryside rises in proportion to the intensification of the armed struggle …. “Health workers should be encouraged to serve in army units … Others, without having to join the army, can play an important role in the consolidation of guerrilla fronts. “On a wider scale, we must mobilize members of the health sector, especially those in the cities, for indirect support of the armed struggle: 1) services and supplies … 2) training … of army health officers, local activists in guerrilla fronts and others … 3) research (e.g., nutrition and plant pharmacologic studies … ).” 5. Uphold the democratic right of health workers to organize and fight for their genuine welfare. “We must form organizations of health workers to fight for their economic welfare through collective bargaining and, where feasible, other forms of struggles like work stoppage, strikes and demonstrations. “… forge unity among health professionals to break down professional hierarchies … “… join professional organizations and transform these from mere social clubs to effective political organizations … campaign for true representatives of the working mass of the health sector to assume positions of leadership in these organizations … raise the level of consciousness of the members of health workers’ organizations. “… relate our struggle to the comprehensive struggle of the masses.” 6. Work for a reorientation of the health educational system and propagate a nationalist and democratic health consciousness. “Either in schools or in our spheres of work, we must continually expose and oppose colonial and elitist values in health care … To know what is relevant in our country, we must conduct social investigation of the actual health conditions of the masses and constantly relate the process of learning with them. them. “We must oppose the commercialization of health education … work for the true democratization in the schools; students from poor and middle classes should be given not only equal chances in admissions but also equal opportunities for finishing. “Finally, we must integrate deeply with the masses. By helping them rely on themselves, utilize their own resources and put up their own health programs, we can slowly crush all values that promote overdependence on drugs, foreign models, hospitals and technology, and the omnipotent doctor for health care.” 7. Promote solidarity with all progressive health workers abroad and seek their support for the revolutionary struggle. “We should develop the closest links with all progressive health workers in other countries, especially those under puppet governments and fascist dictatorships. “… send representatives from among our health workers in the various disciplines to conferences and seminars abroad to share experiences in health and in the struggle for national liberation. “… take every opportunity to arrange forums wherein health workers from genuine Socialist countries, as well as Filipinos who have visited them, can talk about their progressive health care system. “Filipino health workers should be encouraged to return to the Philippines to render service to the Filipino masses and direct support to the Philippine Revolution.” A growing number of health care workers are engaged in the task of forging an alternative health care system based on genuine people’s participation. Experiments in grassroots health care planning have been started in various parts of the country. Their goal is to train health workers in the barrios to pass on knowledge. The focus of the training is on preventative health, and stresses reliance on locally available materials such as herbs. While such programs are still in their infancy, participants are learning both their potential and their limits. They have the potential to challenge the basic premises of the elitist, Western-oriented, institution-based, drug-dependent and profit-motivated health care system prevalent in the Philippines today. They are limited because they cannot function in a vacuum; they inevitably must interact with the economic and political power relations at all levels of Philippine society. If the participants in this alternative health system simply take those relations as a given, the “alternative” is apt to become bogged down by the same problems that plague the existing health care system. The only real alternative, many health workers are coming to believe, is to view the goal of transforming the Philippine health care system in a nationalist and democratic direction as part of the broader task of transforming the basic structures of political and economic power in Philippine society through a national democratic revolution. Health Care As Counterinsurgency
NATIONAL DEMOCRATIC PROGRAM FOR THE HEALTH SECTOR IN THE PHILIPPINES
An Alternative System
>> Back to Vol. 13, No. 2 <<
REFERENCES
“Nurses March for Their Rights,” Tambalan, November 1979, p. 21.