Riding a Tricycle

By Noel Pingoy
Essay

Ten years ago

Sometimes the very things that we loathe strengthen the life in us. As with most of my patients, loss, crisis, and even conflict goad the will to live in ways that are previously deemed unthinkable. People who used to think they aren’t good enough may even astonish themselves with random acts of benevolence and audacity. When it happens, people grow bigger than the impediments that box them, surprisingly too large enough to liberate them from issues that constantly nag and haunt, and consequently live beyond these limitations.

I learned a lot of lessons when I decided to become a commuter six months ago as part of austere lifestyle changes that I believed would define a simple life. In May I gave up my cable TV subscription. A few weeks later I had my DSL disconnected after reaching the minimum period of subscription. Would I say that my life had been more difficult, less exciting, even boring? Au contraire il est difficile de concevoir quelque chose de plus satisfaisant. Instead of spending countless hours in front of the idiot box munching insalubrious junk that augments avoirdupois as much as it encourages ennui, I buried myself in pages of printed wisdom, sweated a little of the excess pounds in the gym, or simply allowed my OC self more hours of sleep and rest that I initially thought were outrageous. I also brushed up on my French, which I had forgotten while attempting to build up the fortitude to remember that the u in gozaimasu and desu is usually not voiced (rather unsuccessfully but I ain’t giving up anyway). The amount that I used to spend for cable TV and internet surfing are instead diverted to the funds of the family council, thus giving some measure to the things that could be easily given up in favor of certain meaningful pursuits that shape and strengthen relationships.

But nothing has taught me more about the wholeness of life than taking the public transport daily to and from work. I am probably the only doctor in General Santos City who is fully dependent on tricycles and habal-habal (motorcycles that ply certain routes in the city, often using the back roads to elude the LTO cops) as I move from one hospital to another. When my driver left without notice at the start of the year, I relied on my brother who lives just a few meters away for my daily rounds until he had to beg off to attend to more pressing concerns. However things are perceived now, I will always remember with deep appreciation and fondness the times together. Since I don’t drive a car, I planned of getting a motorcycle myself to which most of the family and friends disapproved considering the incidence of accidents involving two-wheels in the city. Too unsafe, some said.

It was difficult at first, but in time I discovered what matters and the value of a spartan life. In due time the daily tricycle rides to work became my prayer-in-motion, even a sanctuary from everything that is not genuine in me and in the culture that I grew up to. Where was it written that doctors should drive the latest car models? That doctors who take public transport are kawawa or katawa-tawa? But some people I know believe that to be so. Sitting in a cramped sidecar, stooping so low that I fear my chin would brush my knees anytime the tricycle navigates a hump, I was simply Noel, neither the hematologist nor the medical oncologist, far from the image I have learned to imagine about myself. Inside that vehicle, I often start my day taking my masks off and let go of my self-expectations (even self-importance). Some people I know have dismissed this as something that I don’t have another choice anyway, and it’s true initially. But later I realized that however one goes to work does not really matter at all. I grew up in a society where image and extensions of it in the form of material possessions are valued highly. Sometimes over relationships. People struggle for self-sufficiency, abundance, or mastery and, in holding close these qualities, become blinkered to deeper human truths like humility, respect, and compassion, even contemptuous of anything in themselves and in other people.

This capacity to suffer and accept weakness is a virtue that I have long struggled to overcome. Acknowledging my vulnerability allowed me to connect to other people who too embrace their own vulnerabilities. When I stop pretending to be strong and independent, I draw out the instinctive kindness in other people. By showing this soft side, people tend to be more helpful, more generous, and even more appreciative of what they have. Simple endorphin rush! They feel good about themselves in a noble, unselfish way just being able to hold on a door for someone to pass through it. I live in a village that’s a bit far from the city, so I try to avoid staying out late. Looking back at those six months, I realized how dear friends are, colleagues who are otherwise tired from their busy practice but take the extra pains to bring me home and see me step into the gate safely. In medicine, it is often taught that part of being a professional is to allow for some space, even distance, to be objective. I learned from my colleagues one truth: to truly serve others, one must do it not only with the hands and eyes but with the heart and soul as well.

There is more to learn from life’s precarious edges than being in the safe comfortable middle. Taking the public transport for the past six months has definitely shuffled my belief systems like a deck of cards. While others might see this as something sad or pathetic, there is much wisdom about a card that had been at the bottom of the deck for most of my conscious adult life suddenly turning up the top card, the one that really mattered at the end of the day. My patients with cancer, and now the tricycle and habal-habal drivers, have enriched my life with their example: that no matter how carefully they sort their cards and repeatedly shift through their hands in the presence of death or material inadequacies, the top card is rarely possession or superiority or control. Some people call it respect or goodwill. Doctors who honor the Hippocratic Oath call it harmlessness. Others view theirs as integrity. I call mine love.

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Editors and Contributors

GUEST EDITOR

Eric Gerard H. Nebran is an educator and illustrator from General Santos City. He is currently a PhD Comparative Literature student at the University of the Philippines–Diliman. His research interests include orality, history, and literary productions of his hometown.

REGULAR EDITOR

Jude Ortega is a short story writer from Senator Ninoy Aquino, Sultan Kudarat Province. He has been a fellow in two regional and four national writers workshops. In 2015, he received honorable mention at the inaugural F. Sionil José Young Writers Awards. His short story collection Seekers of Spirits is forthcoming from the University of the Philippines Press.

CONTRIBUTORS

Mikhael M. Labrador is from Koronadal City, South Cotabato, and has been residing in Cebu for the past eleven years, working primarily in the business process outsourcing industry. He is an avid travel hobbyist and a former editor of Omniana, the official student publication of Notre Dame of Marbel University.

Noel Pingoy is a graduate of Notre Dame of Marbel University and of Davao Medical School Foundation. He finished residency in internal medicine and fellowships in hematology and in medical oncology at the University of the Philippines–Philippine General Hospital. He divides his time between General Santos City and Koronadal City.

Mubarak M. Tahir was born in the village of Kitango in Datu Piang, Maguindanao. He earned his Bachelor of Arts in Filipino Language (cum laude) at Mindanao State University in Marawi City. He lived in General Santos City when he taught in the campus there of his alma mater. His essay “Aden Bon Besen Uyag-uyag” won the third prize for Sanaysay at the 2017 Palanca Awards. Currently, he is teaching at the Davao campus of Philippine Science High School.

Lance Isidore G. Catedral is completing his residency training in Internal Medicine at the University of the Philippines–Philippine General Hospital. He also has a degree in Molecular Biology and Biotechnology from UP Diliman. He was born and raised in Koronadal City. Since 2004, he has been blogging at bottledbrain.com. His interests include Christianity, literature, and medicine.

Saquina Karla C. Guiam has been published in the Rising Phoenix ReviewScrittura MagazineSuffragette CityDulcet QuarterlyThe Fem Lit Mag, Glass: A Journal of Poetry, and others. She graduated from Mindanao State University in General Santos City with a bachelor’s degree in English and is currently studying for her master’s degree in Ateneo de Davao University. She is the Roots nonfiction editor at Rambutan Literary, an online journal showcasing literature and art from Southeast Asians all over the world, and the social media manager of Umbel & Panicle, a new literary journal inspired by plants and all things botanical.

Benj Marlowe Cordero from General Santos City is currently working in Dubai as a Sales Coordinator and has yet to graduate from Holy Trinity College of GSC. He spends his days off playing Overwatch, constructing a fictional language for his novel, and completing his poetry collection, under the rose. He likes shawarma, singing in the shower, and Rick Riordan.

Marc Jeff Lañada hails from General Santos City and currently resides in Davao for his undergraduate studies in the University of the Philippines–Mindanao. He was a fellow during the Davao Writers Workshop 2017, and some of his works were published in the Dagmay literary journal. His poems talk about landscapes, especially the overlooked or underappreciated places in General Santos and Davao.

Claire Monreal is a student at Central Mindanao Colleges in Kidapawan City, Cotabato Province. Her poem “Survived a Bullet” is a finalist in the 2017 Cotabato Province Poetry Contest.

Joan Victoria Cañete is a registered medical technologist from Kidapawan City, Cotabato Province. “Superficial Swim,” her poem for this issue, is a finalist in the 2017 Cotabato Province Poetry Contest.

Patrick Jayson L. Ralla is a graduate of Mindanao State University–General Santos City with a Bachelor of Arts degree in English. He is currently working as a private school teacher in Polomolok, South Cotabato, and is taking up a Master of Arts degree in Literature at the University of Southeastern Philippines, Davao City.

Paul Randy P. Gumanao hails from Kidapawan City, and teaches Chemistry at Philippine Science High School–SOCCSKSARGEN Region Campus. He was a fellow for poetry at the 2009 Davao Writers Workshop, and 2010 IYAS National Creative Writing Workshop. He is a former editor in chief of Atenews, the official student publication of Ateneo de Davao University, and is currently finishing his MS in Chemistry from the same university.

Mariz Leona is an AB English student at Mindanao State University in General Santos City. She is from Lambayong, Sultan Kudarat.

Boon Kristoffer Lauw, a chemical engineer–turned–entrepreneur from General Santos City, is currently based in Quezon City. During his practice of profession at a beer-manufacturing plant last 2013, he began to pass graveyard shifts with random musings that eventually took form in writing—and, inevitably, stories.

Erwin Cabucos, born and raised in Kabacan, Cotabato Province, is a teacher of English and religious education at Trinity College in Queensland, Australia. He received High Commendation literary awards from Roly Sussex Short Story Prize and Queensland Independent Education Union Literary Competition in 2016. His short stories have been published in Australia, Philippines, Singapore, and USA, including Verandah, FourW, Philippines Graphic, and Quarterly Literary Review Singapore. He completed his master in English education from the University of New England.

Sharing Soul Stories in Sabtang

by Noel Pingoy (Essay)

Far over the right shoulder as the faluwa leaves Ivana Port in the main island of Batan to thread the treacherous waves of the Pacific Ocean that lead to Sabtang, one can easily spot the ghostly crest of Mt. Iraya looming in a cerulean distance, robed in an incessant pallor that mirrors the breathtaking beauty of this northernmost of the Philippines’ provinces. In a balmy May daylight, the waves glisten even as they briefly petrify the visitors with both their height and their unpredictability, surging onwards from out of nowhere when they are least expected, then remain like petulant juveniles to momentarily shake the boat and its stunned passengers, only to vanish with nary a whimper minutes later. And a peaceful ride is casually resumed.

The faluwa is a seaworthy motorized dinghy that traverses the vast expanse of the waters of Bashi Channel and Balintang Channel, where the Pacific Ocean merges with the China Sea. The boat connects residents from the main islands of Batan, Itbayat, and Sabtang to each other, providing reliable means of transportation for culture and commerce in the islands, the burgeoning tourism industry included. Midway through the trip, our group chances upon enormous waves that whitened the knuckles of some passengers as they held tightly to the railings while ardently mumbling entreaties to the deities. But the steady hands of the skipper and his crew effortlessly steer the boat to slither through the waves like a surgeon precisely and adeptly cutting through the tissue, smooth as a blade, that the faluwa barely trembled in its ascent. A solitary flying fish darts from a distance like some sinewy sliver of silver that skims over the surface as if to taunt the travelers about passing up the exhilaration of the moment just because of a tenuous unease.

The trip to Sabtang takes a little less than an hour, our guide Roger tells us, so enjoy the ride. The group met him the day before, a proud Ivatan in his mid-fifties who knows the infinitesimal details of his proud heritage like the back of his hefty palms. A virtual repository of historical facts and folk trivia, including what sounds like indigenous yarn, he is at ease talking to both the visitors and the locals. The spirit of fun is there all right, but his animated annotations of facts, half-truths and downright trivia are nowhere near mendacity and pretense. Having reached college, his English is almost unsullied despite the obvious trace of the guttural nature of the northern tongues. Sometimes he appears to be chiding the boatmen about not skimming competently enough though this crest of a wave to obviate the vessel’s fretful shudder.

The boatmen are hardy chaps, bronzed from relentless exposure to the elements, the almost mystical mélange of the sun, the wind and the saltwater enfolding the islands and their environs; they are a proud offspring of a race that has been molded by centuries of geographical solitude from the rest of the incessantly shifting world. The Ivatans are typically Malayan but whose features are softer, perhaps gentler is a better word to describe them, than the rest in the northern part of the country. The Ilocanos come across as edgier given the harsh landscape of undulating plains that are amplified by blistering winds, while the tribesmen of the Cordillera ranges are as morose and dour as the cold weather that they are attuned to.

Roger likes to talk a lot, probably comes with the job description I tell myself, but there is nary a trace of contrived earnestness or even perfunctory candor that I would expect from someone who has done this same routine several times in years. His enthusiasm is incredible, but his love for the islands he calls home is even more amazing. Near the end of the trip, when the novelty of the enormous waves is starting to wear out and most of the passengers are lulled to private introspection by the gentle lurching of the faluwa over the waves, Roger stops speaking with a far-off cadence in his voice, and for a long time we sit in silence listening to the waves that beat against the sides of the boat and the winds that thrash the jib. The eloquence of the moment simply distills every person from the frailty of words and everyone allows silence to take sovereignty when it really matters most.

With the near-noontime sunlight the sky is incredibly translucent and the ragged coastlines of Sabtang are now etched sharply against the azure west, assuming an overwhelming loveliness. An imposing lighthouse that stands pompously near the dock provides a picture-perfect preface to the many charms and surprises of the island, the off-white lookout hub sharply demarcating its russet top from the taupe base.

Over the next precious hours, the group will ride through the four towns of Sabtang and be amazed at the simplicity of the Ivatan way of life that has not significantly changed over the centuries, courtesy of its remote location, its tempestuous climate and the tenacity of its people to safeguard the indigenous lifestyle without necessarily preventing outsiders from taking an attentive peek into the heart of their culture. Traces of the old way of life, particularly the fortified mountain refuge called idjang where people hide sometimes for months during the bloody clan wars, are still preserved. Palek, a local wine made from sugar cane, is still consumed by the males to fend off cold and probably tedium especially during the stormy season when they could not head off the coast to catch fish.

The Accidental Writer

by Kloyde A. Caday (Interview)

“Think of it as a simple conversation and catching up, Doc,” I reply as Doc Noel coyly wishes to back out from the interview. I am writing a profile of him as one of the established writers in the region. He obliges, as usual.

After ten minutes, he arrives, and I shake his hands. Concerned with my stomach grumbling and churning, Doc Noel invites me to dinner. Could it be obvious that I am still annoyed at my four-hour ride from Kabacan to General Santos, too unfortunate on catching up a van and bus with malfunctioning air conditioners?

No worries, it’s catching up, no questions on medulla oblongata or metastasis to the omentum, I think, and to smoothen things up, I buy him my latest read, Report From the Abyss by Karl de Mesa. Little do I know he also has something for me: a tin box of hand-picked teas.

Doc Noel deserves his favorite puto bumbong after running chemotherapy sessions to his six patients and grappling under the summer heat on his rounds and consultation. Tomorrow, one of his patients will undergo a bone marrow procedure, and after that he’ll go straight to Davao City for a conference. Yet that’s just the start of his jammed schedule. He sighs, knowing sooner he’ll fly around the Philippines for several appointments and worrying on their newsletter’s impending deadline. Will he still be able to read the books he ordered in Amazon and watch the tournaments of Roger Federer? At least listening to Aegis while on the road is doable.

 

Kapoy pud baya mag-doktor,” the writer-oncologist says. I soon recall Doc Noel’s essay “Being a Hematologist,” which opens with a question: “What eloquent echoes in the mind can a tempest foment?” The beating of rain simply reminds him that the world is designed with a cycle of life, pain, recovery, and loss. His writings allow us to peek at what doctors and patients have to go through: from denial to acceptance, diseases the patients didn’t wish to acquire. Their loved ones are often as beaten as them, but still they hold on to a miracle that someday, the bruises will soon pass.

As a reader who’s tossed inside “the humdrum bleakness of the cream-colored walls of this clinic” and who senses peril in “this antiseptic environment that reeked of an odd mixture of ethyl alcohol and a faint pungent-sweet whiff of some unfamiliar drugs,” I find it difficult to believe that the essays of Doc Noel are not borne out of careful considerations on poetics. I remember him telling me he does not bother with the ladder of abstraction and other checklist of creative nonfiction do’s, so I clarify. “Wala gyud, Kloyde,” he repeats, and tells me his way: (1) he types in his laptop all night; (2) the next day he reads his draft aloud; (3) he changes or omits the terms that constrict cadence. He says it’s all about rewriting and letting your own intuition trust the voice you hear in each sentence.

His vivid showing of doctor-patient stories is an extension of his Hippocratic oath and lifetime mission of serving humanity. Definitely, his essays are a product of listening to his patients twice, curing them within, and treating them not as case numbers but human beings whose strength needs to be dignified amidst the dark period of their lives. Andrea Lim, a co-writer and friend of mine, has this to say: “Noel’s way of writing makes everyone hopeful somewhere in between, that all of us are patients trying to be larger than the symptoms of our imperfections and different phases of pain.”

He claims that there is redemption in telling true stories of suffering, and death may be absurd or far-fetched to some. But creative writing, to Doc Noel, enhances his medical profession. Each weave of his warm and truthful sentences can be chalked up to the good relations he has forged with every patient he has encountered. He values every narrative, transforms them into literature, and reaches it out to people who might be losing hope in their own sort of battles.

 

Doc Noel likes to think he is an accidental writer. Suffice it to say he wasn’t able to guess he’d get read and win writing awards. In his college days, he was the editor-in-chief of Omniana, the student paper of Notre Dame of Marbel University. Supervising the publication, he got only his gut feeling to say one was a good sentence or a bad one.

When “Finding Rest in Lake Sebu” won the travel essay contest in The Philippine Star, he realized that his creative pursuit might prosper. Then again, the oncologist is an oncologist, so he’d end up writing more medical papers instead. In 2002, his essay “Being a Hematologist” won him third prize in the Palanca Awards. Hearing the news, Luis Gatmaitan, another writer-physician, called Doc Noel, who was at that time inside the movie house. He was a proud friend, cheerful even when what turned out to be a simple writing challenge from him earned Doc Noel a writing distinction. Clueless that the Palanca Award is our counterpart of the Pulitzer Prize, and perhaps heavily drawn to the film on the giant screen, Doc Noel said (and I am paraphrasing), “Okay.” This triumph sank in only after a few days when more people recognized his authentic flare for storytelling.

No Muse of nonfiction writing abandoned him when his manuscript qualified for the Silliman University National Writers Workshop. Dominique Cimafranca, his co-fellow, waited for him at the port in Dumaguete. With his long-sleeved polo and a matching tie, what Doc Noel had in mind was that the writing workshop was akin to a medical conference. So when he asked how many quizzes he had missed, Dominique was baffled by the inquiry. This is how the workshop works, Dominique explained: for weeks panelists would evaluate the manuscripts submitted. Fazed, Doc Noel said he’d fly home. Dominique said, it’s your call, but you’ll be hated because thousands of essayists would want to be in your slot. He believed his co-fellow, so he let his scalpels take a break in exchange for a life-changing summer around a tight bond of literary friendship he has cherished since then.

 

Recently, more writers of SOCCSKSARGEN have felt the need for articulating the tales and everyday life in the region, with writing groups established since 2016. Regional writers get younger and younger, teachers start to invite them to share their craft in their classes, and more fiction, nonfiction, and poetry from the writers in the region are published nationally and internationally. This thriving culture of literature was irrelevant and absent a few years ago, but Doc Noel’s unwavering support has contributed greatly to its growth.

I still remember him showing up to check on Jade Mark and me during our writing fellowship in Davao. Truly, he is every SOX writer’s uncle-physician who introduces them to established writers in the country and invites them to dinner. He is their librarian-physician who provides important books they can’t afford. He is their assistant-physician who gets involved with coming up with literary events in the region. Most of all, he is their fan-physician who would temporarily dish out his Neil Gaiman to read their works. It’s very satisfying, he says, that the shining characters you and the gang are showing to me are same as the articles you have written.

As for me, talking to Doc Noel is like getting along with a favorite uncle, who plays pranks with his nephews and nieces, throws jokes at them, and relates the lessons he has experienced in life. You would soon forget the burden he bears while dealing with the constancy of death among the people he meets, both as an essayist and an oncologist.

 

When it’s time to leave the diner, I quickly glance at the note I prepared for the interview. He has already answered all the questions, but there are two dates I have written down: his Facebook posts on March 9, 2015, and February 2, 2017.

“It must have been difficult to write about your mother’s pancreatic cancer, Doc. It’s ironic,” I say. Perhaps it’s my calling, he says, perhaps I was destined to be in oncology, hematology, and palliative care so I can take care of Nanay. And I remember the lines in his essay “Other Disclosures”: “Nanay taught me differently. When I was doing what is probably the most heartbreaking and difficult disclosure, her eyes never left mine and her palms held mine.”

“And what about Inday?” I ask.

“She’s my younger sister, an anesthesiologist. She died in a plane accident in 1998. Her story is something I haven’t written about. Too difficult.”

 

I will drive you home, Doc Noel says. Don’t bother, I say. There’s no traffic. He asks, where is your house? I say, it’s a few steps away from Jade Mark’s. Let’s surprise him, he says. I’d be glad to play a prank, I say.

We arrive at Jade Mark’s room. He says, I wanna sleep on Jayson’s bed, and we point at the unmade bed. He lies down, says, take a picture of me and send it to Jayson. In the end, both of us take a selfie with Jade Mark’s framed picture (Jade says this moment is never off the record).

They walk me home, say goodbye to me, and as Doc Noel disappears from my view, I clutch the tin box of tea he gave. He was an accidental writer, all right, but he has done a pretty good job in his attempt to unravel life’s meaning as he listens well to his patients’ dreams and aggravations. Is there is any sort of accident when his essays brimming with compassion freed me? I think not.

April 20, 2017

 

Acknowledgment
Special thanks to Andrea D. Lim, Jade Mark Capiñanes, and Noel Pingoy.

Other Disclosures

By Noel Pingoy (Essay)

 

Cairns at a Temple

I found a quiet spot at a secluded area at the Heungryunsa Temple away from the babble of fellow tourists and discovered four large stacks of stones. I added a stone to each of them and muttered a silent prayer for the deliverance of my patients from the clutches of cancer and other illnesses, and another for the well-being, joy, and serenity of the people in my life who truly matter—my family and friends.

And I considered myself a man several times blessed for having been given the chance to add something that might be inconsequential in the vastness of the space and time around me but big enough to form a cairn by which my stifled voice and modest share are weighed, along with countless others, to create something big that embodies our deepest yearnings and greatest dreams.

I think this is how humanity survives. One stone at a time.

 

Building Walls

Much of Donald Trump’s rhetorics are beyond comprehension maybe because I don’t understand US politics at all. Or simply anything political. But I’m amused at his plan to build a wall on the Mexican border at the expense of Peña Nieto’s government. To keep the illegals out, he says.

Recently I have also seen friends building walls around themselves in order to keep away the unwanted ones. Some changed numbers, while others blocked or unfriended a few. The best friend has difficulty connecting with his better half because of the many pressing matters to attend to at present. Another friend broke up with a partner because they are better off without each other, believing that they have done horrible things to each other over a relationship that spanned six years. In his woundedness, he thought keeping a safe distance would be a great relief. Still another is navigating uncertain waters even when he knows this has brought him troubles before.

I have seen this same scenario among cancer patients especially after the disclosure of the diagnosis. In their anger, disbelief, dread, or even denial, people put up barricades to shield themselves or their loved ones from the spectre of pain and death that are often associated with the illness.

Nanay taught me differently. When I was doing what is probably the most heartbreaking and difficult disclosure, her eyes never left mine and her palms held firmly mine. “I am blessed so much with this life I am willing to take on what is set for me. I can’t ask for more,” she quietly declared. Despite the knowledge that pancreatic cancer is among the most aggressive, she remained composed and comforting. She was never one to build walls all her life. In my dreams, she would often say, “Before you keep people out, before you set your perimeter, remember to take stock of what you are keeping inside and what you will leave outside of your wall.”

Some believe that a fortified wall is a manifestation of strength. But sometimes our imaginary walls serve like smokescreen for our inherent weaknesses. When I think about my weaknesses, I sometimes see them as anything that flows out of my mind or heart that prevents me from appreciating and accepting things as they are, from seeing the complete picture.

Then in the heat of the moment, in blinding rage or perceived injustice or imagined hurt, people succumb to their frailty, break things that could hardly be mended anymore, often forgetting how precious they are. The irreplaceable are gone.

There are many things that could be broken: eggs, memories, commitments, heirlooms. Even hearts. Which is maybe one of the common things people break. Which is maybe hugot lines have become popular these days.

I’m reminded of a parable by Jose Carlos Bermejo in Regalame la Salud de un Cuento. It’s about a young man who bragged that his heart was the most beautiful in the whole region because it was perfect and did not have a single scratch. A girl told him that she had seen a more beautiful heart—a heart belonging to an old man. They went to the old man, and the heart turned out to be full of scars and had missing pieces.

The old man said that the scars and holes represented the persons he had given his love to. He tore pieces of his heart and gave them to the persons he loved. Many did the same thing to him, and some didn’t, but he continued to love the ones who had caused the holes in his heart because they might someday return and fill the emptiness.

In tears, the young man took a piece of his heart and gave it to the old man, who did the same to him. Now the young man’s heart was no longer perfect, but he found it more beautiful than before.

By laws of simple arithmetic, it would seem that when someone gives himself away to love another, he ends up with less of himself than what he has begun with. But I consider it grace that the opposite is true. Like breast milk. The more it is suckled, the more of it is made. To give herself away in commitment to another human being—like a mother to her child or my Nanay to me—is to break down a wall, to become fully alive. And with living not just for oneself, a person becomes, little by little, slowly and tenderly, human in spite of himself, becoming whole, becoming both loving and lovely.

The last time I saw my newsfeed, the best friend has already “liked” an Instagram post of the girlfriend. The couple on the brink of separation seemed to have gotten back together. And the other friend kept himself alone last night, maybe to think things over.

I have come to realize that even the best and brightest among us could make mistakes. People fall prey to countless emo-tions, exaggerations, and excesses. But we must be brave enough to confront them, to accept with honesty that it is not the frailty of being human that maims us but rather our notion that a strong wall between individuals “could make us great again.”

What matters in the end is our humility with which we know ourselves, accept ourselves, and share ourselves—blemishes, warts, and all.

 

To the Kids in the Family

Your late great-grandparents Adoy and Dicang raised their brood of nine in rural Iloilo under the most trying times. Your great-grandfather was a simple farmer who instilled discipline—some say with an iron hand—and integrity among the seven boys and two girls that came one after the other. Among the most lasting stories in the Adoy lore are his unbeaten streak as the dumog (wrestling) champ in all of Panay and his mastery of the baston (cane) that hadn’t spared even your grandfathers while they were growing up.

But the heart of the family had always been your Lola Dicang, a simple, unassuming woman who taught her family the true meaning of love and respect. She was a perfect foil to the stern and sometimes gruff Adoy, was well liked by everyone but feared by those who threatened to disrupt the peace within her family. She always spoke in a soft, almost-hushed voice that soothed and reassured. Shouting was only for hornbills, not for self-respecting people, she would tell her family. Even in moments of unguarded delight, she still maintained composure and respectability. She led a kapilya (chapel) in the neighborhood and ministered to the members of their small community as a Bible woman while keeping herself preoccupied with raising her nine children. No matter how simple her payag (hut) was, its door was always open to those who needed food or shelter for a night or even a simple banter in a lazy afternoon. That she was blessed with many children was a measure of how richly committed her life was. Having been able to send all her offspring to college is a testament to the greatness of the woman.

She never thrived on gossip and never thought ill of other people, even strangers. She had a ready rebuke to women who dishonor their families by meddling in the lives of others, much more concocting stories about them. She showed her siblings by example how to respect people and themselves. Lola Iya, Lola Dicang’s only sister, was a very soft-spoken and kindly woman who loved feeding us the most succulent chico from her backyard in Calinan. Even Lolo Adoy’s sisters were admirable in their simplicity and gentleness. Lola Soling was content selling tobacco in her papag (stall) in the public market, while Lola Kalaw was an unpretentious homemaker who loved to cook. They never even finished high school, but they led honorable lives in the service of their families and in the sight of God. Disdainful of arrogance and conceit of women who believed that the world was at their feet and that material possessions were essential elements to a happy life, they nurtured their families with genuine love, unfailing loyalty, and boundless devotion. They were selfless with their children as they were faithful to their respective husbands. I am sure that given the chance, you could have learned a great deal about a steadfast life with integrity from these remarkable women.

Having finished high school, which was rare for women in those times, Lola Dicang took pride in teaching others how to read and write. She was never prouder than when a son or a daughter finished a degree. But she was also quick to remind us not to be boastful of achievements and accolades; modesty is a virtue that must be pursued, she once said. “Indi maayo ang bugalon.” And I vividly remember her telling us often about not pursuing success as defined by the world but one that is embodied in her beloved passages, Philippians 3: 12–21.

Your Lola Dicang was a voracious reader. She would often take notes of interesting quotes and inspiring passages from magazines and books, and pass them to family and friends. Lolo Gert, having been the old woman’s darling (as the youngest), received the most letters. Fortunately, he had the foresight to keep the letters that his Nanay had been sending him so that photocopies of these letters were shared with the grandchildren for us to learn from them as well.

The existence of these letters resurfaced when my generation decided to formulate a “code of ethics” by which we hope to live by. For several months, the cousins have been meeting at least once a month to set up a family council that shall guide every member’s pursuit of happiness in the context of belonging to a family and of respecting individuality. Tito Bobot first thought of it after realizing how much we love to meet (sometimes daily) to talk and to eat. He asked why not put these meetings to a good use. It resonated eloquently with the rest of the cousins, and some semblance of organized solidarity has since been in place.

And such initiative came at no better time when the tigulang (elders) were worried about what lies ahead for the family when all of them are already gone. Only your Lolo Saul and Lolo Raul have survived to connect you to the past. Would you still remain united as mga apo sa tuhod ni Adoy kag Dicang (great-grandchildren of Adoy and Dicang), or would you go your separate ways? They also fear about some members being left behind.

Several years back, few uncles and aunts met to discuss the “rules.”

The code runs like this:

Code of Ethics

  1. I commit to a life of excellence, where I support the highest good of people, including myself.
  2. I pursue happiness through relationships that are based on goodwill and respect, through responsibilities in which my contribution is essential and for which I am accountable.
  3. I honor the lives of those who went before me by channeling their teachings as touchstones for a moral and happy life. I bless those who come after me with examples that shall be their guide in their pursuit of happiness. And I bridge my past and my future with a Presence that is greater than myself.
  4. I strive to honor my commitments.
  5. I embrace values that attach importance to relationships over resources, commitments over circumstances. And truth above anything else.
  6. I succeed by playing fair.
  7. I measure my worth with compassion, courage, and character.
  8. I am not alone. I am a member of this family.

Here’s hoping that we have not forgotten this. Waay biyaay (always watch out for one another), sa mga apo ni Adoy kag ni Dicang.

 

Going Home

Every time I go home, I am amazed at how the once quiet community where you knew almost everyone has been replaced by a bustling city with busy traffic, constricting public spaces, and peripatetic strangers.

The old-timers must be baffled at the steady growth of the old hometown, and maybe even more baffled why the next generation is more than happy to embrace the new way of life.

Where my siblings and I used to run around, catching grasshoppers and dragonflies, or where we used to play hide and seek with our pets on warm summer days and with neighbor-friends on moonlit weekend evenings, two-story and even three-story buildings now take space.

But changes notwithstanding, Marbel remains the same place in many ways that mattered to me for ages. The landscape of my beloved town might have altered over a short span of time, but I am comforted by the thought that people take some time to change.

I often discover this when I go home on weekends to be with family. Despite the six-lane highway, friends often stop, wave, and smile when they recognize you. They ask you how the parents are. They tell you how this friend has gout and yet won’t stop his daily dose of beer, or this former classmate whose blood pressure is way up the stratosphere but won’t quit smoking. They tell you how they met old teachers who haven’t aged a bit. They offer you turon kag bandi. They welcome you to their homes like a long-lost brother. They share triumphs and heartbreaks, secrets and anecdotes. Of course, the constant question about marriage and spreading of genes [smiley].

This is the sort of kasimanwa (town mates) I grew up with and got to stay connected after many years.

Summers then were quite punishing in Marbel. I remember the times when brownouts were frequent; we had to stay outdoors often, under the trees, beside a brook, or at my uncle’s farm in Barrio 8. But the start of the rainy season was a welcome relief; the heat was more tolerable, and the constant pouring in the afternoon was an invitation to run around in complete abandon. Since most roads then were unpaved, we had individual puddles in the middle of the street that became exclusive wading pools.

But I sometimes had issues with the beginning of the rainy season. The grasshoppers and dragonflies became scarce. Spiders became rare. Times spent with friends became scarcer with the onset of the rain. I often wished for bright mornings when I could see my friends again.

In my adult life, especially in a profession that exposes me constantly to death and dying, I have learned that the changing of the season is a necessary part of life. That’s how old things make way for the new. That’s how the world remains fresh and bright. Someone dear to me just died early today from pancreatic cancer that has resisted even the most advanced targeted therapy. I had a chance to take care of him for a few weeks and wondered how things as dreadful as cancer could happen even to the best and brightest among us. There he was, barely able to speak, completely under the loving care of his family, slowly wasting as cancer ravaged his mind and body. He would struggle forming words to communicate what he felt or wished. But there was no mistaking the smile of recognition (even of gratitude or of goodwill) each time I made rounds.

Minutes ago, I struggled with what is probably the hardest birthday wish I will ever get to write because the poignancy is not lost in the pain and absurdity of the turn of events. But one that needs to be spoken of nonetheless. He passed away on his wife’s birthday. And the latter is someone I knew all my life, having seen sunsets fall quietly through the acacia trees at the old Notre Dame campus from elementary through high school or quietly enjoyed late evening conversation as we were seated at nearby tables while our respective kids were enjoying burger and soda at McDonald’s. That they are both physicians—he was an ENT specialist; she, a dermatologist—was not lost in the irony of things. Some things happen beyond the realm of human understanding.

Og Mandino once wrote, “I will love the light for it shows me the way, yet I will endure the darkness for it shows me the stars.” I cannot speak of any greater love in my generation than what both of them shared. They are private, soft-spoken, kind individuals. People who were never known to raise their voices. People who could never hurt a fly. And when I think about someone losing her reason for being brave and strong on her birthday, I can only pray that the quiet, tenacious and boundless love that they shared will be the family’s refuge in the uncertain days ahead.

The seasons have destinies of their own, much like my beloved hometown or my friend’s struggle with his disease. Or the chorus of crickets after the rain and the abundance of grasshoppers and dragonflies in summer. I can no more prevent them from transgressing what small of piece of comfort remains in the darkest hours than I can nurture them to the fullest in the greatest of days.

So I just have to rely on memories—Marbel when the creek was teeming with fish, the fields were a playground for grasshopper hunting, my friend waving a heartfelt goodbye and muttering a barely audible thank-you—to help me see through the cold grasp of pelting rain.

And in most cases, even when I know that it is never enough to assuage the burning pain in my chest, I pray.

Becoming a Hematologist

By Noel Pingoy

(This essay won the third prize in the 2002 Palanca Awards.)

What eloquent echoes in the mind can a tempest foment?  This is the second day typhoon Iliang is passing through Manila, and I am midway my three-year fellowship training in hematology at the country’s largest government hospital. There is a somber gray in the constant pouring of the rain, punctuated by paroxysms of strong wind, casting an eerie gleam on the cream-colored wall of the Philippine General Hospital (PGH). Outside, the trees are a wretched sight, most of the leaves are gone; they all shudder with every blast of gale. Most of the patients are still asleep, huddled together with their bantays, while sharing the warmth and comfort of their bodies.  Except for the lonesome Ward 1 nurse on the graveyard shift, bless her lovely soul, who takes a patient’s temperature here and gives another’s medication there, the earth tethers on a tranquil, delicate thread. Gone is the desultory hubbub of strangers who, thrust for the first time into each other’s company without almost nothing in common except for the hope that their respective patients are coming home soon, alive and well, thank God, have congregated into a Babel of pilgrims in search of a miracle, transforming this particular ward into an ashram of sorts.

Forget about the hysteria and the bedlam of daily ward life at the PGH, for at this hour, this very moment, the mood is somnolent and the milieu, doleful. For time to time, a wayward thunder vaults from the shadows of the cold, wind-battered night, and lunges forward with a swift deafening bellow and a blinding flash of silver and ochre, only to be quenched seconds later as if embarrassed by its own impertinence. There is a ghostly glow and an unfamiliar hush all around; even the crickets choose not to stir, they all stoop low to the earth in their refuge from the fury of this thoughtless storm. There is something lugubrious about daybreak in a tempest—it is always a time of dreadful uncertainty, of profound introspection, of a foreboding that unnerves even the bravest and sturdiest of souls.

It is still dark—after all, it is only 3:45 am—and I have just arrived here at the Medical Research Laboratory. I have to be at the hospital before Taft Avenue swells into a knee-deep morass of murky water, of indescribable floating objects, and of who-knows-what’s-in-there, especially that this is leptospirosis season again. The vermin are in their revenge mode once more, a phenomenon that plagues Manila and its suburbs at the beginning of every wet season. In the next two months or so, at least two scores will perish from complications of this foudroyant illness, acute kidney failure primarily.

Crouched in front of the monitor, cupping my palms around a mug of warm brew, while allowing the tepid terra-cotta to pierce my skin in an invigorating sort of way, I delight in the succor it brings at a time like this. From the fragile comfort of the lab’s thick glass walls, I resign to the chilling thought that at this very moment the sun is powerless to lift the darkness’ heavy veil, and except for the adjoining Endocrinology Office that a forlorn flickering bulb can hardly illuminate, there is frighteningly only more darkness. Horripilating by just looking at my reflection on the computer monitor, framed by what seems like a vast, all-embracing lightlessness, it is as if then night finds its meandering way into my medulla oblongata until the darkness without asphyxiates the darkness within, and the mental struggle to keep afloat this illusory fen becomes agonizingly genuine. The cumbrous beating of the rain and the furious rapping of the wind engulf the building, muffling even the grunts of an overworked electric fan that aches for a long-overdue oiling. All I can hear is the thump-thumping of a heart that is midway between panic and chaos, and I am astonished to realize that it is actually my very own.

As my resolve ploddingly wavers I think of the usual mornings that are bathed in the serene radiance of an orange dawn, a subtle portent of a warm and limpid day ahead, and subsequently find myself reminded that even for doctors like me, life is unpredictable as the weather that one has to be well prepared for it—edges, frills, and all. There is something both gravely appalling and lusciously fascinating in the pitipat throbbing of a myocardium that appreciates how pain and suffering can very well provoke a litany of signs and symptoms, both real and imagined, sometimes bordering on the esoteric and ignominious. When mortality is at the crux of the matter, sometimes one forgets to elucidate the substance of pain in terms of endorphins, cytokines and prostaglandins; instead it is a slow, careful untwining of an elaborate tapestry of a singular life, into which its very fabric are woven the sights and sounds of people and places, of pleasures and the pains of the then and now.

I decided to pursue fellowship training in hematology after practicing internal medicine for a year in my hometown in Koronadal, South Cotabato. It is a small but bustling community of just over ninety thousand of the most hardworking and caring people this side of the globe. While it lacks the historical charms of the old Filipino towns or the effervescent hullabaloo of the cosmopolitan cities, its strength lies mainly on a steadily germinating economy that seduces professionals and blue-collar workers alike, from as far as Luzon and the Visayas, to exploit its promise of a better life. It also boasts of a populace that is punctiliously heedful of its social and moral responsibilities, as well as of its duty in securing peace and order as both a collateral and a remuneration for the steady progress that this hometown we affectionately call Marbel is blessed with.

The influx of professionals into town had found me staring at a vast blank wall, both literally and figuratively, as starting a career in a municipality with twelve internists before you was not a languid walk in the part, so to speak. And having been the thirteenth was not heartening, friends and kin would apprise me. For the superstitious, it was not at all encouraging, to say the least. Much to my consternation, even a certificate from one of the country’s best training institutions did not guarantee a steady flow of patients. I realized for the first time in my life how many precious man-hours were spent in putting up an issue of a newspaper; how this exact number of characters was fitted into a given square centimeter while allowing a picture or a cartoon to complement the story. And I even found myself reading the obituary page while reflecting on the gradual and frightening demise of my own practice. I was inclined to believe that this inactivity hebetated my supposedly trained clinical acumen. Duh!  I didn’t survive the torture I went through for more than ten years only to end up like this, a dignified and stethoscoped bum-in-white perhaps, but a bum just the same. I felt like an appendix, to which medical textbooks would ascribe no particular function in the body. Alas, the torment of disuse!  I was destined to become gangrenous in a manner of speaking, and so before I rupture I decided to excise myself from the system. Autohemolysis, they would say.

Given the current landscape of the medical profession in the country, with its cutthroat competition and a seemingly enshrined fixation on titles and accolades, it became clear that getting a subspecialty is a foolproof license to a secure future. After all, even in the remotest of communities, a paradigm has shifted towards patients preferring somebody with several letters after the MD than the old reliable family doctor. Gone are the days when a physician is trusted with removing a boil from an uncle’s back or with delivering the family’s newest angel while prescribing a salve for the patriarch’s arthritis. Nobody even makes house calls anymore. Nowadays we need a doctor for every symptom, and finding comfort in the knowledge that we can easily find one at most centers, at a flip of a page or with a click of a mouse, the concept of a generalist-doctor is not only anachronistic but also deemed foolish.

Yet it was this very same environment that fanned my desire to embrace a subspecialty that is among the least taken in internal medicine. Along with immunologists and rheumatologists, hematologists or “blood doctors” are so few in this country that their annual convention can be held in a function room of a hotel, unlike, say the cardiologists or the pulmonologists who can easily fill up the PICC. Hematology is also one of the least understood of the subspecialties, the last frontier for the adventurous, the ultimate dare for the challenged, or even the singular way out for the pococurante who cannot decide on where to go. While hordes of graduates of residency training programs all over the country claw their way in order to get into a slot in pulmonary medicine or in gastroenterology, few would admit to ever considering hematology as an option. To some it has the least number of patients, and they are not exactly misinformed; most hospital censuses reflect the rarity of blood diseases in this country, at least among adults. The other way to look at it, as my mentors would later point out, is that most cases remain undiagnosed, and subsequently untreated, because there are just a few specialists in the field. To the poor misguided others, it is a boring subspecialty, what with most of one’s hours spent deciphering thin smudges of blood on glass slides under the microscope, and differentiating a lymphoblast from a myeloblast, a basket cell from a true monocyte. Or why this multinucleated cell is simply an osteoclast (a bone cell) rather than a nonhematopoietic element (like a cancer cell from other diseased organs in the body that have lodged in the bone marrow). This is a subspecialty where you wish you were indeed seeing those screaming “faggots” because these immature cells with opalescent, bright orange sticks in their cytoplasm are basically what one needs to clinch a diagnosis of acute promyelocytic leukemia, a highly curable subtype among the acute leukemias in adults.

No fluid has bewitched, bewildered, and beguiled man since the beginning of time more than blood; literature abounds with accounts of its unique power to restore life, to bring manifold suffering and death, and to unleash unbridled passions in men and women, even children, to make life-defining and history-changing acts for the better or even for the worse. Prehistoric man left many drawings in caves depicting wounded tribesmen in battles with either their fellowmen or the beasts of yore, some of them were shown bleeding to death, perhaps the earliest chronicle of man’s acceptance that loss of blood meant loss of life.

This theme is also seen in the Holy Bible as references of “to shed blood” actually meant “to kill.”  One finds in Leviticus 17:11 the admonition that “it is the blood that maketh an atonement for the soul.”  In the same chapter, in the fourteenth verse, it concludes, “The life of all flesh is the blood thereof.”  The descendants of Israel were spared of the ninth plague when the Angel of Death passed over their abodes upon recognizing the blood of lamb smeared on the door of every Jewish household. Egyptians took blood baths for their recuperative effects, while the Chinese believed that blood contained the soul (Neiching, 1000 BC). For the Romans the practice of “taurobolium” was aimed at spiritual restoration. Citizens in ancient Rome seeking rebirth descended into a pit called fossa sanguinis where above him, a priest slaughtered a bull and allowed the animal’s blood to cascade down in a shower upon the beneficiary. In Ovid’s Metamorphosis, Medea was asked by Jason to restore his father Aeson’s life by “taking years off his life and adding them to his father.”  Instead, Medea prepared an alembic of sheep’s blood, wolf’s entrails, magic herbs, and hoarfrost gathered by moonlight, and poured it into the old man’s mouth after she had cut his throat and let out all his blood. Aeson immediately recovered his youth, strength, and vitality.

In the fifth century, a Sicilian philosopher named Empedocles introduced the idea of the four humors corresponding to the four elements that were respected and feared by man since the beginning of time: fire, air, water, and earth. These four humors were blood from the heart and said to embody fire, yellow bile from the liver (air), black bile from the spleen (earth), and phlegm coming from the brain (water). From the principle of the humors, later thinkers were able to derive the basic human characters which everyone is familiar with nowadays. From the Latin word for blood sanguis sprung the word sanguine to describe a lively, ardent, or optimistic personality.

For Christians, the blood behooves a deeper, more spiritual understanding as it symbolizes the passion, death, and eventual triumph of Jesus Christ over evil. The word first appeared in the New Testament in Matthew 26:2 during the Last Supper. Picture this: in a scene straight from Da Vinci’s famous painting, which also happens to be a ubiquitous fixture in many a Filipino dining room, Jesus raising his cup and proclaiming, “This is the blood of my covenant, which is poured for many for the forgiveness of sins,” probably to the discomfiture of Judas Iscariot.  In many of the church rituals, especially of the Roman Catholic faith, the blood bespeaks an inner cleansing that is not unlike the ceremonies observed by the pagan cultures centuries ago. In Hebrew 9, “the law requires that nearly everything be cleansed with blood and without the shedding of blood there is no forgiveness.”

Legends of werewolves and of vampires flourished during the medieval period. While these tales may have factual basis, many historians believe that these stories were encouraged by the leaders to sow fear in the hearts of their people, and for the citizenry to completely bequeath its unflagging faith on the state. The thirst for blood of these malevolent creatures of darkness was only surpassed by the insatiable greed for wealth and power of these “emissaries of light,” as Conrad, in “Heart of Darkness,” called them, people cloaked by the Church and the State with authority and with respectability, purportedly to improve the way of life of the savages and of the common man.

The nineteenth century was characterized by the weakening of the conventional Victorian ideals on behavior and conduct. Women started demanding equal rights with men, persons of all persuasions challenged sexual mores, and social freedom and responsibility became fashionable among the elite. It also saw the birth of two literary creations that have frightened readers from the time the books first saw print, and have continued to do so even until the present, spawning countless versions in every known culture on earth, in every medium possible, film, television, radio, books, magazines, stage, etc. Frankenstein, or The Modern Prometheus, by Shelley, first published in 1818, and Stoker’s Dracula in 1897 both captured the imagination of millions of readers, and brought the significance of blood, albeit in an egregious mien, on the essence of the living, of the dead, and yes, more so, of the undead.

The ancient Filipinos, especially the datus, sealed their most sacred covenants with elaborate rituals that were highlighted by the drinking of each other’s blood, an act known to students of history as blood compact. Andres Bonifacio and his Katipuneros etched their signatures in blood to solemnize their acceptance into the secret society that was aimed at toppling the Spanish regime in the islands.

The investigations of Whipple, Minot, and Castle in the 1920s signaled the birth of modern hematology. What started as an entirely laboratory endeavor that described the different blood elements in terms of shapes, sizes, colors, and other physical peculiarities and, later, their participation in the various processes in the human body, became a dynamic and all-encompassing science that seeks to shed light on the whys and wherefores of diseases, death, and decomposition. Over the last century, hematology has evolved into a subspecialty that employs all the advancements and the technological advantages of manifold disciplines like nuclear medicine, molecular biology, genetics, immunology, biochemistry, pharmacology, and pathology in its quest for answers. Right now, hematologists are at the forefront in mankind’s war against the most dreadful and formidable diseases known to man: cancer, AIDS, congenital anomalies, etc.

In this country, Filipino hematologists organized themselves in 1960, and their society counts less than a hundred fellows and diplomates in its roster as of latest count. Compare that figure with over two thousand cardiologists all over the country. This means that every hematologist is tasked to take care of the needs of over half a million Filipinos; worse, more than half of this number holds clinics in Metro Manila. Wretchedly, an area as vast as Mindanao is served by less than ten hematologists, practicing in only two cities, Davao and Cagayan de Oro.

I answered the call of hematology even though there are other summonses in several directions where the future seems certain. Maybe I decided to be a fool for adventure’s sake although poets on the other hand call it sweet inspiration, even providential perhaps. To go where only few have ventured before, to confront windmills along the way, and to attain my own redemption in the end. After much thought I knew that I can be of more use to the community by choosing a path less taken, though a bit dangerous in its uncertainty, when others would opt for the tried and the tested, and at the same time, be trusting enough of myself to know which door to open, whose hand to take, possibly what flight of fancy to indulge in, in such a way that it will make me weep that it seems utterly possible, just a heartbeat away from one’s embrace, but at the same time as unreachable as the farthest star.

Why hematology? most people would ask, often times sardonically. And the only plausible answer is:  Why not hematology?

One of my patients who will not sleep through this storm is M, a bright-eyed, intelligent, twenty-eight-year-old agriculture graduate from Nueva Ecija. Barely out of college, she has been in and out of the hospital for over two years. The truth is she has been more in than out of it. She has acute myelogenous leukemia, the type which textbooks call the aggressive form having evolved from myelodysplastic disease which initially presented with abnormal-looking cells in the blood. This secondary form of leukemia is even more difficult to treat because it is less responsive to chemotherapy than those who had de novo leukemias.

The disease was first recognized in 1845 by Craiege and Bennett, but it was a German pathologist named Rudolf Virchow who proposed the name leukemia, a Greek term for white blood. How this disease came about it still unknown, but it is a common observation that leukemia, as most malignancies behave, arises from a proliferation of clones of a single white cell. This means that somewhere along the way a mutation has triggered the white cell to shift its demeanor from a well-behaved entity into a shrewd, rapidly multiplying, and pestiferous ogre in the bloodstream. Several studies have linked radiation, exposure to certain chemicals, or inherited genetic abnormalities as culprits in this transformation, although most Filipino patients would deny exposure to these precipitating factors. This transformed white cell called blast is a prolific, insatiable, and puissant bully that deprives the other blood elements, particularly the red cells and the platelets, of their food and shelter in the bone marrow. Not content with merely invading the marrow, the blasts spill out into the bloodstream and cause serious damage to distant organs like the liver, spleen, and brain. When the red cells are decimated, the patient develops anemia and its consequences: pallor, easy fatigability, shortness of breath even on minimal exertion, generalized malaise, and lethargy. As platelets are the primary cells involved in the prevention and control of bleeding, a reduction in its effective circulating population imperils the hapless individual to hemorrhage from any imaginable site, although most commonly from the mucosal surfaces of the gums, nose, and the gastrointestinal tract.

While modern medicine deserves a pat on the back because it has made leukemia among children a curable illness, sadly the same cannot be said for leukemia of adult-onset. Most patients are doomed to die unless they undergo bone marrow transplantation (BMT), a process that purges the body’s entire blood-forming factory, the bone marrow, of its previous contents with megadoses of radiation and cytotoxic chemicals and then replacing it with healthy, viable seeds called stem cells from a matched donor. While this is a standard method of care in most centers abroad for more than a decade, the procedure is still a rarity in the country. Only five BMTs have been done in the Philippines so far, and only one for acute leukemia with, woefully, unsuccessful outcome. What hematologists in the country can offer is a sort of a temporary fix, a shot in the dark, albeit an expensive attempt to obliterate the leukemic blasts with the hope of allowing the normal bone marrow elements to retain a sense of equilibrium that governed the internal milieu before the blasts overturned everything. This is achieved through chemotherapy, the administration of powerful drugs intravenously. The goal is, as a rule, not complete cure, because sooner or later, the blasts are destined to bounce back into the circulation like a nightmare that could not just be shooed away; doctors can only expect a remission, a technical term for restoration of the normal cell populations while keeping the leukemic blasts under restraint. How long can the drugs keep the blasts at bay is still a matter of conjecture even to the most seasoned of hematologists.

Where cheer previously resided, her eyes, now jaundiced and forlorn, betray an exhausted gladiator who has seen several battles and is on the verge of giving up. Her skin is bronzed from what doctors diagnose as iron overload from multiple blood transfusions; as of last count she has received no less than eighteen bags of packed red cells, not to mention over thrice as many platelet transfusions!  Not that she minds this at all. M is one person who is not impressed by outward appearances, and she could not care less about what others would say about how she looks so long as she is in the thick of her battle for life. She has simple dreams of finding employment in Cabanatuan in order to help her father send the younger siblings to school, and she could have easily done so having been gifted with charm, intelligence, and character. But fate seems to have other plans for her.

When reviewing her medical records one cannot help but wonder how life can harshly turn its back on one person after sealing a covenant of a cloudless future with her. While not necessarily living comfortably, her parents saw to it that M and her siblings receive the best education Nueva Ecija has to offer. I still do not understand why life can be so generous with one person yet take away just as much, even more, in a wink of an eye. Yet for some strangely blithe reason, M has never uttered a word of despondency; for her, every trip to the hospital, however difficult and painful, is merely a step to wellness. Needles are constantly inserted in search of those elusive veins or into her hipbone to draw out her marrow, with nary a word of complaint or resignation. And for several months, she has been confronting her illness with the heart of a true warrior—relentless, confident, and determined.

Every bone marrow aspiration—the process of puncturing the bone on the backside to extract the very substance from which all blood elements originate to evaluate disease progression—is for her an almost solemn ritual of exorcising the demons of this disease that consumes the body of its strength and robs the skin of its color. The procedure is not altogether painless despite a few milliliters of an anesthetic called lidocaine, a puncture remains a puncture, and the anesthesia may not work sometimes. But she regards pain as an indubitable catalyst for holding the fort in this struggle to remain alive. She may be wondering now how long she can hold on; how hope can sustain her protractedly enough to endure every pain, to force herself to stay awake, wide-eyed and fretful, through tedious and fearsome nights lest she forgets to wake up in the morning, and to thank every friend and kin who has gone out of his way to donate blood, to offer a word of encouragement, to shell out a modest amount for her hospital needs, and still come out triumphant in the end over this dreadful illness.

Her father has already given up since the other day when this storm emerged from nowhere and lashed out its fury outright without trepidation; their properties have either been sold or mortgaged, and still without a slightest improvement in sight. Every day, she seems to be getting worse despite the multiple transfusions and extensive antimicrobial coverage. A vial of an antibiotic like a third-generation cephalosporin costs approximately three days of a minimum wage earner’s labor, and M needs at least three vials daily. The land has been left untilled, the weeds have long grown tall, and her siblings have temporarily left school as the family’s finances have been drained by M’s frequent hospitalizations. Her father has arranged for the local ambulance to transport her back to Nueva Ecija, against doctors’ advice, as “it is cheaper to bring home the dying than the dead.”  This will officially be entered in the hospital records as HAMA, “Home Against Medical Advice.”

Unknown to most people outside of the health profession, this term is one of the most abused and bastardized excuses when doctors fail, when they do not know where else to turn to, or simply when science is all but helpless to come up with answers. When I was a resident-in-training, few colleagues would rather choose that their terminally ill and difficult-to-diagnose patients go HAMA than face the wrath of the gods of Science Hall, a.k.a. consultants during the medical audit. Most physicians in this situation hardly know whether to laugh or weep for it scares the daylights out of them to realize how infinitesimal their grasp of the basics is despite years of training, especially in dealing with pain and dying, perhaps in the context of medicine being a calling basically to improve life, to prolong survival, and to alleviate suffering. But aren’t these the very things patients expect from their doctors?

Society has inducted doctors into an exalted position, to almost supernatural status in every known social order, but in return also expects physicians to wield not only control and mastery over disease and death, but sometimes even extraordinary and metaphysical powers over them as well. And this is where the problem lies. All of a sudden the physician is thrust into a predicament, both sublime and grotesque at any given  moment, surreal and very real in the same breath, where he is confronted with the very same fiend that appalls him—to look inside himself and recognize that beneath the veneer of knowledge, of authority, and of respectability, there is something in him that remains ignorant, unsure, and even wicked.

Unconsciously, mortality is one word a doctor would take great pains to avoid in his practice. This fear may be deftly concealed under the strange sounding and difficult-to-pronounce medical terms, all that gobbledygook, or behind the most sophisticated of gadgets and the most modern of diagnostic examinations. It must be remembered that however farfetched, at the end of each day, when the last drop of medicine has been given and the final test has been run, every physician longs for a knowledge far more powerful than what he has in his grasp, just to be able to explicate every symptom, to comprehend in a clinically sound approach a new-onset sign, and to confront not only the slightest pain of the patient and of the patient’s family, but his own personal demons as well. One thing is certain:  While a physician may venture into the most comprehensive of differential diagnoses with the most advanced battery of tests in his armamentarium and with the most powerful drugs in the pharmacopoeia, and even pursue with relentless passion the most exotic and improbable of a working impression, the thought that the patient is going home alive and well and that he is able to return to a normal productive life remains, certainly for physicians, the central joy of every voyage, the Shangri-la of every clinical adventure.

M may be wondering about how slowly death will descend upon her, claim her from the land of the living, and transport her to some unknown planet. Heaven, as the children’s song goes, is a wonderful place, full of glory and grace. But she will surely miss her family, her brother most especially.

She has heard numerous stories of mute resignation, of complete surrender and of utter powerlessness in face of death among her fellow Ward 1 occupants, especially those blessed with a spirit that has continued to be unbowed to the ravages of disease on the body, those who stubbornly remained unyielding to Death’s siren song, but without financial competence to bear the medications and the laboratory tests. She cannot forget Divina, a widowed mother of three who was sent back from the Middle East after her employers found out she had leukemia. She has long exhausted the hard-earned savings she had carefully kept while working as a domestic helper in faraway Bahrain. Now what will happen to her kids’ education?  Then there’s Juliet, a washerwoman who boasted she could finish off a ton of laundry with nary a sweat, but who could now barely wipe the blood off her swollen and foul-smelling gums, her hemoglobin level is so low she sometimes speaks incoherently. Another friend is Veronica whose bone marrow has long ceased to function, making her vulnerable to even the slightest insults of disease, changes in weather, or minimal physical activity. Time is running out even faster for Veronica, but her mother is not giving up, not yet, she says. “I still believe in miracles, so we’re fighting back the illness,” she would tell anybody who dares apprise her of her daughter’s prognosis. Her hurt is palpable, her fear, unnerving, but she refuses to let go, constantly bargaining with anybody who cares to listen, with a resilience that is simply beyond belief.

Oftentimes, the minutes surrounding a patient’s death are characterized by several renderings of bargaining: the patient wishing to stay behind, but also praying that should she go, may it be swift and painless; the family fighting for survival in the face of physical, emotional, and financial exhaustion, waiting for a miracle of restoration and wellness and leaving everything under God’s supreme will and tender mercies, but at the same time questioning His providential wisdom why this grave adversity should befall the best and the most benevolent of individuals; the doctor hoping to revive the patient in one instance, but disbelieving the usefulness of all these efforts in the next.

Then there is the drawn-out, oftentimes ardent, and impassioned tug-of-war for the patient’s cadaver for an autopsy. Medical science has long accepted the need for a postmortem examination (1) to determine the actual cause of the patient’s demise, (2) to establish several theories of disease causation that were never fully explored during the patient’s stay in the hospital, cases that were simply beyond the realm of human knowledge to explain or of the most modern technology to elicit the basic answers to the ultimate question why the deceased had this disease at all, and (3) to simply reassure themselves that doctors did nothing to cause or to hasten the patient’s death. Medical residents would take pains to beg, to bribe, or to bully the surviving members just to obtain that most precious consent.

M is relieved she will never go through all this vivisection and pathologic analyses as she is going home anyway. But for Divina, Juliet, Veronica, and several others, most of whom she knows only by face, the likelihood of an autopsy remains a forthcoming circumstance. Given the chance, she would like to ask, with all the courage she can muster: “Doctors, when you cut my friend with the sharpest of your scalpels, mount them on glass slides with the most vivid and intelligible of stains, and look under your most powerful microscopes, will you be able to tell me what I knew all along: that Veronica or Juliet or Divina died of a broken heart?”

She has seen death one too many, and while accustomed to the impetuous rush of adrenaline that possesses not only the medical staff but onlookers as well during the preterminal minutes, she may be agonizing about how swift will her own be. Will the resident on duty be earnest enough to squeeze her heart during the cardiopulmonary resuscitation and propel ample blood to reach the brains and other vital organs, but also gentle enough not to fracture her ribs while doing so?  Will their resolve be stronger than their physical strength, and their hearts, softer than their minds?

They say that people on the throes of death witness snippets of their lives in two minutes. What will M see in that penultimate moment?  A hand guiding her as she takes the first step?  Maybe palms that rub her back to comfort her during the first heartbreak?  Will she be seeing the knuckles of an intern as he draws out blood for the post-transfusion platelet count?  Or perhaps the touch of a physician in one of his rounds in the morning?

That M should remember the hospital, this ward particularly and its colorful denizens, where she has spent most of the last fourteen months of her brief life, infuriatingly perhaps, painfully to most extent, but fondly above all, challenges all but the remotest explanation, and in a night made more heartfelt by the soaring chorus of rain, wind, and thunder, this is an occurrence worth celebrating. Knowing how fervently she longs for home, I am certain M is praying that the final scent she will derive joy from is that of her own room in the outskirts of Cabanatuan, with the sweet-piquant fragrance of freshly threshed rice stalks wafting through her bedroom window and occasionally perfumed by the faint bouquet of jasmine and ylang-ylang.

But she has also come to love the alternating smell of disinfectant and of body fluids, of bodies rotting away and of bodies recovering, of lives that ebb and of hopes that eddy at PGH. I guess this is the very essence of my being here notwithstanding the shadow of death that pervades this place like a proverbial Damocles’ sword:  PGH even in a storm as malevolent and as forgiving as this is no less essentially meaningful or inherently awe-inspiring than St. Luke’s Medical Center or Massachusetts General Hospital, or any other antiseptic piece of land and sky in the world.

What defines a hospital is the manner it enshrines itself in the heart of those who have been there, not whether it is poorly lit or amply lighted, high-tech or just being able to make do with the available resources, extensive or limited, equipped with a centralized air-conditioning system or simply ventilated with ceiling fans. Every hospital, like any person, caregiver or cared for alike, is characterized by the love and compassion that flow in it, by the hope it kindles even in the most emaciated of bodies, and by the simple joy it nurtures from the lysis of fever or from the mere alleviation of pain, like the burst of warm sunshine on a cloudy day. For the patients, it is basically how their doctors “treated” them, that beyond the relief from physical suffering and the treatment of an affliction, they are not seen as mere case numbers in his list of urgent aggravation for the day; instead, they are also regarded as breathing and feeling human beings capable of getting hurt and of being happy. These acts of loving-kindness, both random and deliberate, will always be remembered first and forgotten last.

This calls to mind a portion of Rabindranath Tagore’s “Fruit-Gathering” that can very well be the prayer for both doctors and patients alike:

Let me not pray to be shielded from dangers but to be fearless in facing them.

Let me not beg for the stilling of my pain but for the heart to conquer it.

Let me not look for allies in life’s battlefield but to my own strength.

Let me not crave in anxious fear to be saved, but hope for the patience to win my freedom.

Grant me that I may not be a coward feeling your mercy in my success alone; but let me find the grasp of your hand in my failure.

The rain continues to pour with nary a sign of ever abating, but the thunder seems to have slipped away. Despite the lingering cold and darkness, there is something encouraging now about the newfound stillness, a sense of quietude that carefully strips away layers of malaise and of hopelessness limning the scene just moments ago, bequeathing each individual who happens to witness this changing of the milieu a heart of raw courage and a soul of palpitating expectations. Then one realizes how once in a while life can be so eloquent it speaks powerfully that it catches him off-guard, forces him to sit up and listen with open-mouthed wonder, and like the docile schoolboy that he once was, allows each word to sink in deliberately, with such explicitness and authority, with neither quandary nor skepticism.

Another day is drawing near. Time is impetuously knocking at morn’s door, it cannot conceal its impatience, the abrupt shift in temperature from chilly to lukewarm is discernible. Amidst all these musings and perturbations, life goes on, yes, even in the middle of a raging storm. There are other patients to attend to, tasks to carry out, forms to fill out, medical records to review, bureaucracy to wrestle with, peripheral blood smears to scrutinize, and coagulation tests to process; the list is downright endless. One looks forward to these duties with a sense of exasperation, these predicaments simply cropping out of nowhere to becloud an already gloomy day, tagging along problems as dark and as uncertain as the landscape one sees outside the lab’s windows. And when all seems lost and senseless, it is as if an unseen hand sweeps one’s vision with an unexpected pause. Suddenly, the heart skips a beat, the tense muscles slacken, the spirit soars, and the mind clears. The problems ahead may indeed be dark, but at this very moment, they are nowhere to be seen.

Instead, one witnesses with an open mind and a welcoming heart lessons which his patients have been telling him for some time now, things that matter most, values that mirror each individual’s loftiest yearning, not only of the patients, but of physicians as well, his own including. Hope. Duty. Love. These things he discovers in this hospital, right now, inside this small laboratory, in the middle of a powerful storm, though none as powerful as the realization that everything happens for a purpose, which neither chance nor coincidence can claim for itself. These are sublime gifts entrusted to a physician, especially to a hematologist, by M and all other patients: the opportunity to improve their lives, the power to take away their pain and suffering, and that singular shot at a second chance for life. To be reunited with their loved ones. To consummate a significant unfinished business. To see the children grow up and watch the garden bloom. Simply, to live. What powerful men do doctors, particularly hematologists, make!  And it seems ironic that amidst the emaciation of the human flesh and larceny of life itself, there are defining moments when hope overcomes, when duty overpowers, and when love overflows, like the one that keeps him in glorious contemplation. Technical jargon and supposedly scholarly pyrotechnics may leave one cold, but a mother’s extremely pale, outstretched hand in need of transfusing so that she can tie a ribbon on her little girl’s hair, a young lady’s pair of jaundiced eyes, despondent at first glance but Pollyannaish on the next, or an unexpected rush of restoration that accompanies every dribble of the platelet concentrate it is so overwhelming one can actually hear it swirl and ramble inside the intravenous tubing, painting a tableau of unmistakable eloquence that simply takes the breath away.

Can this be true, that my choice of specialization is correct, however painstakingly and determinedly I rationalize this action?  This is a rather strange profession to be in, and an even stranger calling to pursue what others call a tedious and adynamic subspecialty, where financial rewards are few and far between. This might be madness. It might even be foolishness. But one can always afford to be mad, to be a fool, in order to hear the barely perceptible whispers from afar, cries for comfort, and summonses for survival, than pay attention to the reproach and pontifications of others, no matter how well meaning they might be. The final truth remains: one may hear a patient’s plaintive cry, or take a fleeting glance on M’s (and several others’) morbid pallor, or grieve over the utter impotence of the present setup to cure diseases like leukemia, and yet is able to appreciate what hope promises, what duty stands for, and what love represents, because these are precisely the very same things—hope, duty, love—that bring enough warmth and comfort to endure this storm, or any of life’s for that matter.

In a couple of hours, M will say goodbye to her ward mates, to the nurses, and to the interns. The discharge papers will be released, and the ink for the final signature will have long been dried. Then father and daughter will take the painful, bittersweet journey home. M will become another statistic in the hospital records, another case number in the computer file. I will bid M farewell, and before she leaves, we will say a prayer together. We will ask for an improved weather, for a smooth ride home, and for the miracle of healing. For the gift of stillness. For tender mercies and for divine graces. For acceptance of things that will remain the way they are. With heads bowed, we will say a prayer of thanksgiving, how knowing each other has enriched our lives far stronger than any storm that has ever traversed our paths.

I will hold her hands, clasp them tightly between mine, and be awed at how gaunt they have become since that first meeting at the clinic, how may months of affliction have stripped away their fullness and their strength, how somebody this fragile can display so much determination and courage to face this seemingly hopeless battle. Had I been a good and caring physician?  Had I treated her kindly enough despite the poor prognosis, and competently enough despite the limited resources?  I do not know, and I may never will; M is not the kind of patient who bothers physicians with such questions. Looking at those soulful eyes, I can only but wish that someday I might know the answers.

Deciding to become a hematologist in this country exposes a physician to a lot of risks. It simply becomes an adventure, a well-calculated wager, in which the stakes are high, but the rewards are gratifying. The tasks ahead are daunting enough, but a matter of faith it is apt to be because, however ambiguous and frightful, a doorway was opened, an artery was lacerated, blood was shed, and however precarious, one has to hem the crimson torrent in. There will certainly be hardship and woe along the way, but even behind the many walls of doubt and of ignorance the questioning mind has to go on searching for answers. It is concerned specifically with the unfortunate few who are afflicted with leukemia and other life-threatening diseases of the blood. And when one is blessed enough to realize that the power he holds in his hands to make a difference in his patients’ lives is at the very heartbeat of this adventure, there starts pulsing from it a kind of promise and conviction that everything will be just fine.

It may take an entire lifetime for me to fully comprehend the wisdom of my decisions, of my actions, or even of my indiscretions, but I am not in a hurry. The world outside is still dark, and I can well afford to tarry until the path is brighter, until the road is clearer. Time when used wisely remains a faithful friend, and enduring a waiting game is perpetually a virtue of conquerors. I will meet more patients whose stories may be as tragic as M’s, but I no longer need to be afraid. They have taught me well, and I am eternally grateful for that. In the future, science will certainly unlock the disease’s deepest secrets and eventually unearth the answers. All it takes is a simple faith. The storm will come to pass, and it will be morning again.

There will be countless and equally life-affirming stories of man’s audacity, his fortitude in the face of sickness and death, of heartwarming tales of each patient’s struggle to survive. Blessed are the patients who come into a doctor’s clinic, brimming with hope, awash with joyful expectation, to bare their life’s histories and their own mortal bodies down to the minutest blood cell in search of a cure, but more blessed is the physician who earns their confidence and fealty, the patients will lay open their hearts and minds to be probed and to be studied. They will literally entrust their lives to him. They will ask him to remember them always, and I honestly believe that after memorizing every sulcus and gyrus in the human brain, as well as the kinetics and dynamics of each drug listed in the manual, most doctors have the gift of remembering. And what about M? She will be special, for experience has a strangely bittersweet way of telling us that in the conduct of human relationships, the one who is never forgotten is usually the one who never asks.

I look out of the window and recognize a fragile streak of light hovering in the horizon.

Choosing the path “To serve Humanity!” is, by any standard, a way of life. To share the patient’s burden is to remember that warm sunny day when one entered medical school, innocence and dignity intact, armed with the values from home and fueled only by the desire to be of use to others. This is the direction of every doctor’s goal—the future seen from afar from his highest ambitions and his truest dreams. By becoming a blood doctor, one of the few hematologists in the Philippines, I am bound to claim that promise, and seeing my patients water the earth with tears of joy and of pain, through their bruises, nosebleeds, and even mortal hemorrhages, as well as their remission and their healing, I share in their laughter as well as in their grief, and in the process, even without my realizing it, make their prayers my own. My very own.