While writing down orders beside the vibrant glow of a Christmas tree, I received a query from Jude Ortega, an editor of Cotabato Literary Journal, about our friend Gilbert Tan. In a flash, the message crushed the placating anticipation of a rather difficult working day that was about to end. I had just discussed the likelihood of end-of-life care with the husband of a patient with stage 4 colon cancer when Jude forwarded a screenshot of a post about Sir Gilbert’s unexpected passing. I scarcely had ample breathing spell to recover from the thought that two kids might be orphaned within the next few hours, then this sudden jolt to the gut. It left me nauseous and dazed.
Realizing that I was at Sir Gilbert’s favorite hospital, I immediately proceeded to the Emergency Room. I had traversed the expanse from the third floor to the ground a thousand times during the customary rounds, but inexplicably my pace was unsteady and the steps were heavy. The resident-on-duty, a keen young “moonlighter” with a thoughtful demeanor, confirmed with heartbreaking certainty that our dear old friend had just been declared DOA—dead on arrival—despite over thirty minutes of steadfast cardiopulmonary resuscitation.
For many of us who have been following the literary scene in this part of the country, the late Gilbert Tan was not only a mentor, guide, and taskmaster but a torchbearer for the advancement of the written word in General Santos City and neighboring towns. He was the first in the region to have been accepted to the National Writers Workshop in Dumaguete way back in 1989, and he was among the earliest to be recognized in a national writing competition when his short story “Crimson Crescents”—an unforgettable and tragic tale of love, faith, and acceptance involving a Christian nurse and a Moro insurgent during the tumultuous Black Shirt–Ilaga conflict in Mindanao in the early seventies—won the grand prize in the 1988 Mr. & Ms. magazine contest.
For many years, even after his retirement from teaching at Mindanao State University, he had been a lecturer and a judge in many a division, regional, and national schools press conference. Many student journalists in SOCCSKSARGEN had learned about the craft from him in extents that count writing—and by extension, reading—as a commitment, a passion, and an abundant cradle of joy. He paved the path for many younger writers to seriously pursue a kindhearted, almost altruistic, love affair with the written word, one that is bereft of personal gains or regional cliques.
When the editors of Cotabato Literary Journal first thought about coming up with a special “Illness” issue, they decided to have it in the last quarter of the year in solidarity with promotion of health awareness among its readers. Aside from the usual time constraints, the last month of the year was deemed appropriate as December 12 is celebrated as Universal Health Coverage (UHC) Day. The date marks the anniversary of the first unanimous United Nations resolution calling for all countries to provide their citizens affordable quality health care. The commemoration aims to raise awareness of the need for strong and resilient health systems and universal health coverage with multistakeholder partners and for UHC advocates to raise their voices to share their stories of the millions of people still waiting for health. In the Philippines, the Universal Health Care Bill has been signed into law (Republic Act No. 11223), thus giving every Filipino access to the full continuum of health services he needs while protecting him from enduring financial distress in the process.
Based on the talk I gave last year at Notre Dame of Marbel University (NDMU) in Koronadal City, South Cotabato, on behalf of the writers’ organizations in the region, this special issue would be called “Naming Our Wounds: The Illness Narratives,” a reflection on the power of medicine to mitigate human suffering, the inevitability of compassionate methodology to diagnose and treat the ill, the inequity of the medical institution in the upkeep of the physician, and, in a larger and more collective scope, the responsibility of society in cultivating the physical, spiritual, and intellectual welfare of doctors and patients alike. But the editors did not imagine the subject would hit home the hardest.
Way back in 2014, both Sir Gilbert and I had an intimate brush with death when we had cerebrovascular accidents (more commonly known as the stroke). I had mine in March, while he had his admission to the Intensive Care Unit in June. That we both survived this ordeal was a testament to the body’s tenacity to endure and to rewire the brain in what experts would call neuroplasticity, as well as the astute and well-timed interference by a multidisciplinary team of specialists that scrutinized, decrypted, and remedied the myriad pathologies that constituted this life-threatening illness. Neuroplasticity or brain plasticity is the ability of the brain to modify its connections to enable the brain to recover from brain injury like a stroke. The brain is unique in its capacity to recruit its many neural connections in correcting a transient deficit of function by rerouting signals along an entirely different pathway.
Over the next years, Sir Gilbert would regularly write about his struggle with post-stroke recovery and the occasional anxieties with abnormal laboratory results or unanticipated symptoms. He was known to share many things on social media about the world around him—and even within himself—especially the books he had recently read or acquired. He would often write about his stroke as if it were a metaphorical wound that needed incessant tending. Two years ago, he quoted the first lines from Pat Conroy’s The Prince of Tide: “My wound is geography. It is also my anchorage, my port of call.” That would define, to my mind, his daily battles and little victories in the years preceding his untimely death.
In another post, he also mentioned Nelson Mandela’s “wounds that can’t be seen are more painful than those that can be seen and cured by a doctor.”
The Chiron myth, as discussed in the NDMU lecture, is a reminder of the multidimensional exile that wounded people inhabit during and after a serious illness. According to Greek mythology, Chiron was unlike the other centaurs that were known to have wild and barbarous tendencies and insatiable sexual appetites. He was the product of an unwilling union between the nymph Philira and the god Chronos. Disgusted and appalled by his appearance, Philira rejected and abandoned her child. Fortunately, the sun god Apollo adopted Chiron and taught all that he knew: prophecy, poetry, and healing.
Chiron formed a strong friendship with Heracles, among the mightiest in the Greek pantheon of heroes. They fought in battles together, side by side, on many an occasion. But Heracles accidentally wounded Chiron when he shot an arrow that struck the centaur’s knee. The wound was incurable because the arrow had been dipped at the gall of Hydra and was extremely lethal.
But Chiron, being immortal, could not die. The animal part of him had to suffer, while the divine part maintained his connection to life. For this reason, he became a renowned healer. He studied herb lore and therapeutic methods and became a medicine man in search of cure. He would never find one, but he found something better, something more consequential—a door to transcend his misery and become truly whole.
Without Chiron, many contend, there would not be the art of healing. Asclepius, the son of Apollo, learned medicine from the benevolent centaur. The descendants of Asclepius continued the practice of medicine and healing. Undoubtedly its most famous member was Hippocrates, immortalized as the father of modern medicine, who was credited by historians with moving the discipline of medicine away from supernatural and religious conviction toward a modern approach of observation, classification, causes, and effects.
Carl Jung, inspired by the myth of Chiron, defined the archetypal wounded healer as thus: “The doctor is effective only when he himself is affected. Only the wounded physician heals. But when the doctor wears his personality like a coat of armor, he has not effect.” Chiron may have been physically wounded, but by surmounting the pain of his own wounds, he became a compassionate teacher of healing. Many contemporary psychotherapists see themselves as “wounded healers” in their respective societies, whereby they use the pain of their own life experiences to advance the health and healing of others.
In The Wounded Storyteller, professor of sociology at the University of Calgary Arthur W. Frank describes sick people as wounded storytellers. These are people who turn illness into stories that transform fate into experience. The disease that sets the body apart from others becomes, in the story, the common bond of suffering that joins individuals in their shared vulnerability.
A serious illness like cancer, stroke, AIDS, dementia, systemic lupus erythematosus, even chronic kidney disease, is a loss of the axiomatic “destination and map” that previously guided the ill person’s life. People with illness have to learn to think differently. By listening to themselves tell their respective stories, they learn by absorbing the reactions of others and by experiencing their stories being shared.
It has been said that all of literature can be divided into two themes. First, a person goes on a journey. Second, a stranger comes to town. While this might be terribly naive, there is gist of truth in it. And it is also true that narratives of medicine merge both these themes. A person goes on a journey: the person is the patient, and accompanying him on the voyage is the doctor. A stranger comes to town: the stranger is the illness, the uninvited guest who disrupts the equilibrium of quotidian life, where the journey leads, how the two voyagers change over the course of the story, and whether the stranger is ultimately expelled or in some way subdued give each narrative its unique drama.
In this issue, we follow in An-Nurhaiyden Mangelen’s heartbreaking “An Ama Reverie” a grandson’s struggle with his family’s journey from a village in Maguindanao to Cotabato City and finally to Davao City, where a beloved patriarch, brain-dead from a stroke, had to be unplugged from life support. It is too shattering to read about “all the injections, the bedsore he had gotten from not being able to move around, or even the sensation of not being able to function and be the master of his body the way he wanted to.” Despite the author’s world-weariness, the restorative power of stories cannot be ignored when he noted: “In the seven-day grieving period, hundreds of people came to his house in Dalican to pay their respects; the stories I heard about him that day, like the one on my parents’ wedding as well as tales of his unselfishness, made me see him in a better light.”
General Santos City’s adopted son Wilfredo Pascual (formerly of Nueva Ecija and now based in San Francisco) writes about nocturnal enuresis, commonly known as bedwetting, as both a natural manifestation and a metaphysical depiction of his struggle with mental illness. Unarguably the most accomplished writer to contribute to this issue, his “River of Shame” is a master class of astute craftsmanship and frightening candor that every student of literature should read and learn from. When he describes his “family across the river. They looked so happy. It was so beautiful it hurt,” one commiserates with a young man’s tender yearning for his rightful place in a world that excludes, discriminates, even punishes the ones that need help.
In “The Long Wait to Cure,” Koronadal’s Dr. Lance Catedral’s account of Faith, who has mesenchymal chondrosarcoma, is for me a familiar occurrence, having trained at the Philippine General Hospital many years back. “These people came from all over the Philippines,” he notices. “They brought with them tumors of different sizes and shapes, of varying degrees of aggression, in various parts of their anatomy.” This is a typical, often depressing, refrain in a country where more than half of the patients are seen in the advanced stages and “people pay for their treatment out of their pockets.”
It is heartening to know that Dr. Catedral belongs to an emergent population of Filipino physicians who appreciate the role of narrative in medicine in improving clinical practice and in understanding the subjective experience of illness as a platform through which a sick person can express his shifting awareness of self and identity in measures that are not merely expressive but transformative and therapeutic as well. Among the Filipino doctor-writers (or writer-doctors) I admire for a profundity that obscures the once-inalienable line between technical writing and scholarly/creative prose and for refined bravura on the printed page are the obstetrician-gynecologist Alice Sun-Cua, medical anthropologist Gideon Lasco, neurosurgeon Ronnie Baticulon (whose first book Some Days You Can’t Save Them All is now on its second printing), Palanca Hall of Famer and pediatrician Luis P. Gatmaitan, internist Joey Tabula (the second edition of his anthology Through The Eyes of a Healer is much anticipated), surgeon Jose Tiongco, infectious disease specialist Louie Mar Gangcuangco, geriatric medicine specialist Eva Socorro Aranas Angel, and the brothers Yu, theater reviewer and multihyphenated Vincen Gregory and endocrinologist Mark Gregory.
The art of telling stories and of listening to stories used to be central to the doctor–patient relationship. Patients have stories that need to be heard, not just symptoms that require knee-jerk stipulation for CT scan or prescription of medications. When patients complain of pain, it could be something that is psychosocial as much as somatic. When the concept of well-being is threatened, something that challenges an individual’s concept of being around for family and for meaningful relationship with peers, emotions, thoughts, and stories impact how an individual understands pain, disability, and death.
The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” The word arises from the Latin poena or the Greek poene, meaning “price paid,” “penalty,” “punishment.” This association, malignant as it may seem, has roots hidden within the illness-experience. It is a common belief among Filipinos that a serious illness like cancer or AIDS is a punishment for something a person has done. When a person is gravely ill or is in severe pain, he is evicted from the quotidian sequence of characters upon which so much of his traditional individuality is based. A man ceases to be a husband, father, breadwinner, and best friend all at once when serious illness rears its ugly head.
Out of the appreciation that restoring meaning to the subjective experience of illness and suffering that was mislaid in the predominantly objective perspective in which clinicians are trained, narrative medicine emerged in the late nineties. Internist Rita Charon coined the term narrative medicine and started a movement that was aimed at improving the communication and collaboration of health care professionals and their patients and at bridging the gap between humanities and the sciences. Arthur Kleinmann, Robert Coles, Arthur Frank, Brian Hurwitz, Trisha Greenhalgh, and many others became leading advocates for greater recognition to patient narratives.
Over two thousand years ago, Hippocrates stated that “it is more important to know what sort of person has a disease than to know what sort of disease a person has.” Arthur Kleinman, a medical anthropologist and psychiatrist, clearly distinguishes “disease” from “illness” in which the former refers to the biological problem that science addresses and the latter characterizes the human experience of the disease. Complete medical care tends to both disease and illness. He wrote, “Each patient brings to the practitioner a story. That story enmeshes the disease in a web of meanings that make sense only in the context of a particular life.”
In the past, there was meager attention on language, both the spoken messages and the nonverbal communication doctors provide their patients and impart among themselves. The words of a doctor have immeasurable clout, received by the sick and their loved ones with enduring resonance. Despondently sometimes doctors hurriedly discard ordinary speech and take on formulaic phrases of the wards:
“Excision of adenocarcinoma is optimally done according to standard protocols.”
“Cardiac arrhythmia led to disordered circulation that disrupted cerebral perfusion.”
“Remission rates can be as high as fifty percent with neoadjuvant chemotherapy.”
Espousing abstracted language was part of enlisting into the medical guild and served its goal of shorthand transmission of knowledge among professionals. Such communication was once regarded as absolute and all-encompassing and was conveyed with noble intentions. But all too often it was ambiguous to a layperson and carried out to abbreviate or even cease more discussion. It also worked to curtail a doctor’s scrutiny of the values and beliefs of people before him—the patient and family members—individuals seeking an explanation that made sense to them as people, not merely cases. Doctors needed to explain what this technical information meant not only for their hearts and lungs or kidneys and liver but also for their soul. The diagnosis and treatment were just doorways to a discourse about the emotional and social impact of a particular condition and what the doctor was purporting to do about it.
When doctors write about their experiences and those of their patients, it compels them to revisit a more ordinary language, one that, while still clinically precise, is truer to feelings, perceptions, and sensibilities. Such writing enables doctors step down from the podium of the professional and plumb their internal and external persona from more human perspectives.
In her seminal work on personal account of illness, Reconstructing Illness: Studies in Pathography, Anne Hunsaker Hawkins added at the end:
Another voice we need to hear is that of the physician. This may seem a paradoxical statement at the end of a book that so insists on returning to the patient to the medical enterprise and so often contrasts the patient’s voice to that of medicine. But the “physician’s voice” I am referring to . . . (is) the voice of the individual who is inevitably lost in that impersonal professional voice. We need to hear from them . . .
We need more writing that conveys the inner reality of what it is to be a physician in today’s technological medical system. Only when we hear both the doctor’s and the patient’s voice will we have a medicine that is truly human.
In Harry Potter and the Deathly Hallows, a teacher of wizardry asks Hermione Granger whether she wishes to study the Magical Laws to pursue a career in magic. “No,” she says. She wishes to learn the laws so that she can do some good in the world. For Granger, magical laws do not exist to propagate magic. They are tools to illuminate the world.
Similarly, a physician studies literature and, if given the opportunity, writes about these stories to give meaning to the pain and suffering, the struggles and redemptions, of living in the world of disease and decay, death and dying, dread and deliverance.
This 40th issue also included three outstanding works of fiction that explore the multifaceted dimensions of healing. Literature abounds with fictive ills, works that have disease or wound as its nucleus. Sophocles’ Philoctetes is a valuable source for imagining the phenomenology of illness, one that, like its protagonist, is exiled to the uninhabited island of Lemnos, away from the customary world, because of a foul-smelling wound on his foot. He happens to stray into Chryse’s coppice and is bitten by an asp whose venom creates a putrescent wound that never kills and never heals. The wound that is the cause of his exile for nine long years becomes his identity, echoing Sir Gilbert’s favorite opening line from the Pat Conroy novel. Other literary works that illustrate these fictive ills are Charles Dickens’s Bleak House, Anton Chekhov’s Ward Number Six, Henry James’s The Wings of the Dove, and my favorite, Leo Tolstoy’s The Death of Ivan Ilych. The short story by Chekhov, himself a medical doctor, depicts a philosophical conflict between Andrey Ragin, the director of a provincial mental asylum, Ivan Gromov, one of the institution’s patients. Tolstoy’s novella follows the main character’s journey from a “most simple and most ordinary and therefore most terrible” bureaucrat with an incurable illness to a perceptive human being who ultimately and serenely comes to terms with the constancy of death in life.
In this issue, the fiction pieces are similarly arresting and enlightening. Koronadal’s Dianne May Torres (“Jellyfish”) portrays a girl’s menarche as portent of something graver when she gets older; John Efrael Igot from Magpet (“Epidemya ng Lipunan”) depicts a parallel theme between an insidious skin disorder and the scourge of dubious government policy; and Lebak resident Jean Martinez Fullo (“Wag Tularan”) submitted a cautionary tale which co-editor Jude imagines as having an “ultimate intention” of “[asking] us how we, as a society yearning for order, have lost empathy and regard for the rights of others.”
In these stories, and even in the lone poem in this issue by Banga’s Adrian Pete Medina Pregonir (“Kanser”), we are confronted with the face of suffering. The writer-persona laments the loss of the very source of nourishment as a child to breast cancer (Hindi na bango ng daisy, santan, yellow bell/ang pragransyang nanunuot sa aking mga baga/kundi ang bulok na suha at saging/anastrozole at dekstros sa ICU.) Recognizing these wounds reminds us of the multifaceted banishment of the ill from the land of the living: the perception of sickness as corporal, cognitive, and cosmic punishment; the loss of faith in the providence of the divine and in the benevolence of society; the foreignness of one’s body and the estrangement of the person to the meaning of self; the obliteration of human roles especially at home and work; the disarticulation of language; the uncertainty of time and relationships; and the loss of geography as an anchorage or port-of-call to which all voyages begin and end.
I had the good fortune of sitting beside Sir Gilbert at a local coffee shop three nights before his fatal heart attack. He greeted me with his customary warmth in between giving sagacious advice to, I assumed, his former students. I remarked that he particularly looked serene and content. He just smiled back. I will always carry that memory with me like a wound that cannot be healed. It has become, in my appreciation of—and gratitude for—his life and death, a personal geography.
Noel P. Pingoy
Koronadal, South Cotabato
Charon R. Narrative and medicine. N Engl J Med. 2004; 350(9): 862–864.
Charon R. Narrative Medicine: Honoring the Stories of Illness. Oxford; New York: 2006. Oxford University Press; 2006.
Charon R. Narrative medicine as witness for the self-telling body. Journal of Applied Communication Research. 2009; 37(2): 118–131.
Chekhov A. Ward Number Six and Other Stories, trans. Hingley R. Oxford: Oxford University Press, 1988.
Conroy, P. The Prince of Tides. Boston: Houghton Mifflin, 1986.
Frank A. The Wounded Storyteller. Chicago: University of Chicago Press, 1995.
Greenhalgh, Trisha. Narrative based medicine in an evidence based world. British Medical Journal 1999; 318: 323–325.
Hawkins AH. Reconstructing Illness: Studies in Pathography. 2nd ed. West Lafayette: Purdue University Press, 1999.
Jung C. Fundamental questions of psychotherapy. Princeton, NJ: Princeton University Press; 1951.
Macneill PU. The arts and medicine: a challenging relationship. Medical Humanities 2011; 37: 85–90.
Kleinman A. The Illness Narratives: Suffering, Healing, and the Human Condition. New York, NY: Basic Books; 1988.
Rowling, JK. Harry Potter and the Deathly Hallows. New York, NY: Arthur A. Levine Books, 2007.
Sophocles. Philoctetes, trans. Greene D. Chicago: University of Chicago Press, 1957; 1959–1960. New York: New American Library, 1960.
Tolstoy L. The Death of Ivan Ilych, trans. Maude, L.
Wald HS, McFarland J and Markovina I (2018): Medical humanities in medical education and new practice. Medical Teacher. DOI: 10.1080/0142159x.2018.1497151.