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This is to certify that the

dissertation entitled

CULTURAL POLITICS OF DISEASE CONTROL:
STATE-COMMUNITY RELATIONS IN THE STRUGGLES
AGAINST MALARIA IN THE PHILIPPINES

presented by

Eufracio Cubacub Abaya

has been accepted towards fulfillment
of the requirements for

Ph ° D ° degree in Wgy

 

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CULTURAL POLITICS OF DISEASE CONTROL:
STATE-CONIMUNITY RELATIONS IN THE STRUGGLES
AGAINST MALARIA IN THE PHILIPPINES

By

Eufracio Cubacub Abaya

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Anthropology

1 994

ABSTRACT
CULTURAL POLITICS OF DISEASE CONTROL:
STATE-COMMUNITY RELATIONS IN THE STRUGGLES
AGAINST MALARIA IN THE PHILIPPINES
By

Eufracio Cubacub Abaya

This dissertation addresses the dynamics of domination, conformity, and
resistance in the struggles against malaria involving the state health functionaries and
an Ilokano community in northeastern Luzon, Philippines, in the early 19905. It
analyzes these dynamics in terms of the concept of cultural politics, defined as the
encounters of power-laden cultural schemas taking place in contestations over
definitions of and responses to social reality at a given time.

Using historical records, this study describes the key features of the schema of
malaria control espoused by the state. The analysis shows that the schema upholds a
well-entrenched epidemiological orientation, adheres to a top-down health policy
formulation and implementation, champions the rhetoric of ”malaria blocks economic
development,” and depends heavily on financial and technical assistance from
international health and development agencies.

Using surveys, interviews, and participant observation, this inquiry analyzes
the llokanos’ cultural understandings of the body, health, sickness, and healing. In

practice, these understandings indicate the rootedness of the physical presentations of

sickness such as malaria in the social and moral spheres of daily experience.
Moreover, these understandings have resulted in the reconfiguration at the local level
of the definitions of malaria, including the global antimalarial strategies such as
spraying of houses with insecticides, treatment of bed nets with pesticides,
environmental engineering, case finding and treatment, and community participation.

Grounded in asymmetrical power relations, the encounters between the state
health functionaries and the Ilokanos reflect the contradictions between the state
schema of malaria control and the Ilokano ethnomedical knowledge and practices.
These contradictions contribute to the persistence of local apathy, ambivalence, and
resistance towards the official antimalarial strategies.

This study of the cultural politics of the state-community relations in the arena
of disease control aims to contribute to the current discourse on the inseparability of

culture, power, and history.

Copyright by
EUFRACIO C. ABAYA
1994

To my late Tatang and Inang,
for their enduring commitment
to the education of their children

ACKNOWLEDGEMENTS

The United Nations Development Program/World Bank/World Health
Organization Special Programme for Research and Training in Tropical Diseases
provided financial support for both my graduate studies at Michigan State University
(MSU) and field research in the Philippines. The Department of Anthropology,
University of the Philippines, allowed me to take a leave of absence from teaching
and concentrate on my graduate studies. The Department of Anthropology, MSU,
also provided financial assistance for my graduate work. The Institute of
International Health, MSU, allowed me to use their office facilities. I am most
grateful for their generosity.

To my guidance committee--Drs. Ann V. Millard (co-chair), Herbert Whittier
(co—chair), Harry Raulet, and Judy Pugh-~thanks for being unstinting with your time
and patient in your mentoring.

I acknowledge Dr. Jeff Riedinger, Department of Political Science, MSU, for
serving as the dean’s representative during my dissertation defense. I benefitted
immensely from his thoughtful comments.

I owe special gratitude to the people of Masipi and to many friends and
acquaintances in various offices of the Philippine Department of Health for making
field work an enriching and unforgettable experience. I am also grateful to Dr.

Realidad S. Rolda, former chair of the Department of Anthropology, University of

vi

the Philippines, for her sustained support while I was conducting field work in the
Philippines.

I extend my special thanks to Michael C. Ennis-McMillan and Martin
Manalansan IV for helping me Shape and sharpen my arguments.

To Dr. Donna Chollett, Walter Russyk, Suparna Braskaran, Krishnakali
Majumdar, and David Canales-Portalatin, I am grateful for their comments on earlier
versions of this dissertation. Vandana Goswami and Min Chuan Yang joined me in
confronting the challenges of dissertation writing.

My efforts would not have come into fruition, however, without the unfailing
support of my two field assistants (Jessie and Marlyn), my relatives (sister Gee and
her husband, Alex; sister Faina; brother Lex; nephew Ernie; niece Gina; nephew
Jonathan; grandniece Detdet; sister Fely and her husband, Ron; nephew Dan; brother
Doti and his wife, Robin; niece Jo; and nephew Andre), my friends in the Philippines
(Dr. Emma Porio, Che Cheng-Dominguez, Boy Dominguez, Ernie Acosta, Linda
Bulong, Orly Turingan, Tess Guanzon, Mary-Ann Octaviano, Pearl Patacsil, and Dr.
Edmond Dames), and my friends in the US. (Drs. Pat and Herb Whittier, Drs.
Isidore Flores and Ann V. Millard, David Canales-Portalatin and Michael C. Ennis-
McMillan, Sonia Padilla and Ron Dietz, Charito Bermejo and David Adrikovich,
Martin Manalansan IV, Dr. Donna Chollett, Dr. Renato Linsangan, Dr. Cheribeth
Tan, Sue Saguiguit, JoAnn Palma, Glenda Soriano, Dr. Rudie Altamirano and Let
Carpio-Altamirano, Rene Cerdena, Zandro Martinez, Manny Viray, Lilian Gadrinab,

and Rey Ebora). To all of them, I owe a lifelong debt.

vii

PREFACE

My engagement with the anthropology of disease control began in 1985 when,
as a member of the faculty of the Department of Anthropology at the University of
the Philippines, I was invited to participate in a WHO-sponsored research project on
malaria in my country. Focusing on the knowledge, attitudes, and practice (KAP) of
communities with respect to malaria and its control in Cabagan, Isabela, the research
examined the extent to which people’s KAP cohered with that of the state’s
antimalarial program. The research was predicated on the assumption that the results
would constitute a vital input to health policy formulation and implementation. In
particular, the results of the research were considered to be useful in designing health
education strategies to ”modify" people’s ”erroneous" KAP and, consequently,
generate wider community acceptance of state-instituted antimalarial strategies borne
of the knowledge claims of biomedicine and the biomedical sciences, as well as of the
economic and political goals of national and international health and development
programs.

This dissertation radically departs from that previous investigation. It
represents my effort to avoid a stance that privileges biomedical knowledge and
practice over other culturally specific forms of knowledge and practice, a stance that
elides the issue of power that inheres in the interactions between the so-called "health

providers" and ”target beneficiaries,” and, finally, a stance that ignores the

viii

embeddedness of social dynamics in historical processes. In addressing these
compelling issues, I drew inspiration from interpretive and critical perspectives in
social anthropology as applied in the arena of health and suffering. I have, for
instance, followed the lead to ”denaturalize" biomedicine by designating it as a social
and cultural domain. This orientation made me more sensitive to the ways in which
the culture of biomedicine interacted with the local cultural forms; and, by extension,
to practices of domination, conformity, and resistance engendered by these
interactions. 1 turned my attention to the ways in which the structure and orientation
of the antimalarial program condition and, in turn, are themselves reproduced
through, the encounters of the antimalarial program actors with the Ilokanos in
malaria-endemic settlements in Cabagan, Isabela. Analytically, I viewed these
activities as manifestations of cultural politics--that is, the dynamics of meaning and
power in socially situated negotiations and renegotiations over definitions of reality.
Having framed the workings of the antimalarial program in terms of the notion of
cultural politics, the dissertation can be considered as falling under the rubric of
studies that regard health and suffering as key loci for the investigation of the
interplay of culture, power, and history.

The process of writing this dissertation, I must admit, was punctuated by
difficulties arising from the intellectual and personal experience of an author as a
positioned observer. For instance, I had to confront the raging issue of objectivity
versus subjectivity in social scientific writing by meshing survey data and historical
accounts with transcripts of interviews and discourses obtained in actual encounters

among the health workers and the villagers.

ix

The virtue of reflexivity in my study of the struggles against malaria lies in the
fact that it led me to reexamine the extent to which ethical and moral orientations
have influenced the course of this project, given the social milieu of my field work
and academic pursuits. My being a member of academe, the empathy I have with
people in subordinated groups, the financial support for my doctoral studies from the
World Health Organization (a key participant in the arena of international health and
development) and my being an Ilokano, all contributed to the dilemma of being

deeply engaged with the politics of writing.

TABLE OF CONTENTS

List of Tables xiii
List of Figures xiv
Chapter One: INTRODUCTION ............................................................... 1
The Problem and Theoretical Concerns ............................................... 1
Cultural Politics and Social Theory ........................................... 4

Notes on Malaria Studies in the Philippines ................................. 7

Chapter Two: METHODS AND RESEARCH SETTING .............................. 12
Data Gathering Strategies .............................................................. 12
Historical Research ............................................................. 12

Ethnographic Research ......................................................... 13
Representations of Masipi .............................................................. 26
Supralocal Representations .................................................... 26

Infralocal Representations ..................................................... 31

Chapter Three: THE PHILIPPINE ANTIMALARIAL PROGRAM

THROUGH TIME .......................................................... 38
The American Colonial Administration (1898-1935):
"Beginnings of the Battle Against Malaria" ................................ 39
The Commonwealth Period (1935-1945):
"The Campaign Deteriorates" ................................................ 48
The Post-Colonial Period (1946-1990s):
"Shifts from Control to Eradication to Control" .......................... 50
Concluding Remarks .................................................................... 69
Chapter Four: MALARYA IN OUR MIDST .............................................. 71
Ilokano Ethnomedical Knowledge and Practices ................................... 72
The Fate of Ligaya ............................................................. 73
Experiencing Mam .......................................................... 79
Concluding Remarks .................................................................... 95

xi

Chapter Five: ENCOUNTERS OF CULTURAL SCHEMAS ......................... 96

Antimalarial Program-Community Dynamics ...................................... 97
Disseminating Official Knowledge:
Voices from Above ............................................................ 98
Local Participation Needed ......................................... 106
Malaria Control and Economic Progress ......................... 107
Contracting Malaria and Everyday Routines .................... 109
Surveillance and Submission ....................................... 110
Dispelling "Local Misconceptions” ............................... 111
Mosquitoes as Culprit ............................................... 112
Which Mosquito? ..................................................... 113
Plasmodia-Mosquito Connection ................................... 114
Deciphering and Treating Malaria ................................. 114
Malaria ls Fatal and More: Scare Tactics ........................ 116
Reconstituting the Bed Nets ......................................... 117
Official Malaria Control Measures ................................ 119
Instilling a Sense of Community Responsibility ................. 121
Personal and Collective Obligation ................................ 122
Contesting Resistance to House Spraying ........................ 123
Undermining the Reserba Mentality ............................... 125
K-Othrine is Safe ..................................................... 127
Presuming People’s Acceptance ................................... 128
Concluding Remarks ................................................. 131
Responses to the Malaria Control Program:
Voices from Below ............................................................ 133
House Spraying ....................................................... 133
Case Finding .......................................................... 139
Drug Distribution ..................................................... 141
Community Participation ............................................ 142
Concluding Remarks ................................................. 149
Chapter Six: CONCLUSIONS .............................................................. 151
Truth Claims and Malaria: The Limits of Cultural
Domination and Resistance .................................................. 151
Appendix ......................................................................................... 159
Bibliography ..................................................................................... 161

xii

Table 1.
Table 2.
Table 3.
Table 4.
Table 5.
Table 6.
Table 7.

Table 8.

Table 9.

Table 10.
Table 11.
Table 12.
Table 13.
Table 14.
Table 15.
Table 16.
Table 17.
Table 18.
Table 19.
Table 20.
Table 21.
Table 22.
Table 23.
Table 24.
Table 25.
Table 26.
Table 27.
Table 28.
Table 29.
Table 30.
Table 31.
Table 32.
Table 33.

LIST OF TABLES

Offices, hospitals, and clinics visited ............................................. 15
Sample population ................................................................... 22
Age of respondents .................................................................. 23
Birthplace of respondents ........................................................... 23
Educational attainment of respondents ........................................... 24
Principal occupation of respondents .............................................. 25
Health-related legislation promulgated during the early U.S.

Occupation ............................................................................ 43
Malaria control and related activities during the rehabilitation

period (1946-1950) .................................................................. 55
Bilateral and multilateral foreign aid agencies and private

foundations ........................................................................... 57
Reasons that malaga is dreaded .................................................. 81
Reasons that malaga is not dreaded ............................................. 81
Cases of malaria reported in each household in the last year ............... 82
Causes of specific cases of mm in the household ........................ 84
Reasons that villagers are vulnerable to m .............................. 85
Reasons that nobody in the household has had m ...................... 87
How mam is transmitted ....................................................... 88
Measures to prevent malaga ...................................................... 89
Characteristics of tyempo iti malma ............................................ 90
Therapies for mam .............................................................. 91
Biomedical drugs .................................................................... 92
Plant medicines ...................................................................... 93
Purposes of spraying ............................................................... 134
Duration of the efficacy of the pesticide ....................................... 135
Reasons that households submit to house spraying ........................... 136
Reasons that households refuse house spraying ............................... 136
Reasons that the pesticide is washed off ....................................... 137
Reasons for collecting blood smears ............................................ 140
Whether the residents can control mama .................................... 143
Reasons why villagers cannot control mama ................................ 144
Activities that residents can do to control mam ........................... 145
Whether health personnel and residents should become partners .......... 146
Activities of residents and health workers to control malarya .............. 147
Reasons that partnership is not feasible ......................................... 148

xiii

Figure 1.
Figure 2.
Figure 3.
Figure 4.
Figure 5.
Figure 6.

Figure 7.
Figure 8.
Figure 9.
Figure 10.

Figure 11.

LIST OF FIGURES

Municipality of Cabagan in lsabela Province, Philippines ................... 14
Research Sites: Magallones, Compra, and Sagpat ............................ 16
Magallones ........................................................................... 17
Compra ............................................................................... 18
Sagpat ................................................................................. 19
Outdoor Economic Activities, Malaria Transmission, and Mosquito

Density ............................................................................... 20
Forest Concessions in the Cagayan Valley .................................... 28
Distribution of Malaria in the Philippines ...................................... 32
Organizational Structure of the Philippine Public Health Rehabilitation
Program .............................................................................. 52
Organizational Structure of the Philippine Malaria Eradication

Program .............................................................................. 63
Organizational Structure of the Malaria Control Program ................... 68

xiv

Chapter One

INTRODUCTION

The Problem and Theoretical Concerns

In the Philippines today, malaria persists despite several decades of state-led,
nationwide antimalarial efforts. The state attributes this failure partly to its difficulty
in ensuring local participation in antimalarial activities. Through shifting approaches
and strategies, the state continues to contend with people’s responses ranging from
ambivalence to outright refusal to involve themselves in antimalarial activities. This
study examines this problem in terms of the concept of cultural politics. By cultural
politics1 I mean the encounters of power-laden cultural schemas2 in contestations over
the definition and management of life circumstances. These contestations, by
extension, engender practices of domination, conformity, and resistance.

This study characterizes the historically grounded precepts that underlie the

 

1Ortner (1989az200) provides a complementary definition, that is, "the struggles over
the official symbolic representations of reality that shall prevail in a given social order at a
given time. "

2In espousing the notion of power-laden cultural schemas, I am following the position
of Comaroff and Comaroff (1992:28) in regard to the prevailing criticism leveled against
cultural analyses that fail to "add" power into the equation. This criticism contends that
power "determines why some signs are dominant, others not; why some practices seem to be
consensual, others disputed-even when they are backed by the technology of terror "
(1992:28). While subscribing to this general point, both authors argue that "power is not
above, nor outside of, culture and history, but it is directly implicated in their constitution and
determination. It cannot, therefore, be ’added’ to them " (Ibidz28). They argue that power
and culture are inseparable in that "power is an intrinsic quality of the social and the cultural;
in short, their determining capacity" (Ibidz28).

2

divergent ways malaria is understood and dealt with by the state health functionaries
and by the Ilokano-speaking farmers and wage laborers residing in a malaria-endemic
area in northeastern Luzon. I examine how these precepts, situated and actualized
within characteristic power relations, configure the social encounters between the
Ilokanos and the state-paid health workers. My purpose is to show how the obstacles
encountered by the state health apparatus in advancing its antimalarial activities in a
given social setting are embedded in superordinate-subordinate relations between the
government health functionaries and the Ilokanos.

In casting the problems of the Philippine antimalarial program in terms of
cultural politics, my analysis asserts that cultural forms and their expressions are
socially contested or negotiated. This study, therefore, focuses on the processes of
contestation over the official antimalarial program run by the state, under the auspices
of international health and development agencies. Specifically, it examines the
contested character of meaningful cultural forms such as the body, malaria, sickness,
therapy, and disease control. This analytic stance, however, does not deny the shared
nature of cultural forms. Yet, in recognizing culture as shared, it asks, following
Dirks et al. (1994), "By whom?” and ”In what ways?” and "Under what conditions?"

As a concept, cultural politics is useful for directing attention to superordinate-
subordinate relations in a given social setting. In this study, I focus on the encounters
between the Ilokanos and various state institutions and agencies, particularly the
health care bureaucracy. I posit the following questions: In what ways and under
what conditions has the state been addressing the problem of malaria among the

Ilokanos? In what ways and under what conditions have the Ilokanos been responding

to that state initiative?

These questions speak to the workings of ideology3 and social control in the
cultural politics of the antimalarial campaign. In broad terms, ideology comprises the
doctrines and precepts espoused by a particular social group in terms of which the
social world is interpreted. Social control refers to the ways of enforcing public
conformity with socially prescribed modes of action (cf. Waitzkin 1991:7). In this
study, I view the antimalarial program partly as a medium expressing an ideology of
the state’s health bureaucracy. To achieve public conformity, the state creates and
maintains structures and mechanisms for social control, notably, its organized health
system that advances antimalarial strategies, which entail surveillance and control of
"target” communities. This process is shaped by a system of power relations that
interact with and sometimes subjugate precepts and practices of the community. In
practice and through time, the state’s official modes of defining and dealing with
malaria have to contend with the ethnomedical knowledge and practice of the target

communities. One aim of this study is to examine the interplay between the state’s

 

3My conception of ideology is informed by that of Williams’s which regards ideology
as "an articulated system of meanings, values, and beliefs of a kind that can be abstracted as
[the] ’worldview’ any social grouping subscribes to..." (1977:109). Moreover, I subscribe to
Comaroff and Comaroff’s (1992:29) assertion that

[t]he regnant ideology of any period or place will be that of the dominant
group, although the degree of its preeminence may vary a good deal; so also,
will the extent to which it is empowered by the instrumental force of the state.
But other, subordinate populations have ideologies. And, insofar as they try
to assert themselves, to gain some control over the terms in which the world
is ordered, they too will actively call upon them--even if only to clash their
symbols. [italics added]

4

ideology and the ideology of the Ilokanos.4
Cultural Politim and Social Theory

Until recently, issues of ”resistance to modern health care,” now redefined as
"resistance to scientific medical bureaucracies” have been primarily explained in
terms of "lack of fit” between biomedicine and ”folk" medicine (see Foster and
Anderson 1978; Paul 1955). This approach to medical encounters, which is
apparently informed by modernization theory, has been criticized for not only
suspending epistemological scrutiny of biomedicine but also for its inattention to local
and global power relations that produce and shape sickness (Morsy 1990).

Arguing against analyses that regard biomedicine as a natural system,
Kleinman (1978) views biomedicine as a cultural system in and of itself. He explains
the problems arising from clinical encounters as resulting from the limitations of the
physical reductionism inherent in biomedicine in dealing with the experiential
underpinnings of other culturally constructed ethnomedicines. Kleinman’s concept of

"explanatory model"5 has proved to be a useful analytic device to examine clinical

 

4This view relates to a point made by Comaroff and Comaroff (1992:29), stating that
the ideologies of subordinated groups are kindled by contradictions, "contradictions that a
prevailing culture no longer hides. " This stance resonates with that of Williams (19772109),
who argued that

[a] lived hegemony is always a process. It is not, except analytically, a
system or a structure. It is a realized complex of experiences, relationships,
and activities, with specific and changing pressures and limits. In practice,
that is, hegemony can never be singular.... It has continually to be renewed,
recreated, defended, and modified. It is also continually resisted, limited,
altered, challenged by pressures not at all its own. We have then to add to
the concept of hegemony the concepts of counter-hegemony and alternative
hegemony, which are real and persistent elements of practice.

5He defines the notion of explanatory model as a set of beliefs which "contains any or
all of five issues: etiology. onset of symptoms, pathophysiology, course of sickness and

5

encounters. It calls attention to the divergent definitions of reality that come into play
in clinical encounters.

The "explanatory model" approach, however, has been questioned for focusing
on the individual as the object and locus of significant events, a feature of
biomedicine that Kleinman and his followers criticize (e.g., Good 1977, 1986; Good
and Del-Vecchio Good 1982). Young (1982) argues against the use of explanatory
models of illness as the primary source of explanation for the surface meaning of an
individual’s statements. In his view, individuals appropriate different kinds of
socially determined and dialectically related knowledge. Additionally, he argues that
ignorance of these socially embedded processes of knowledge construction contributes
to the reproduction of conventional medical knowledge (Young 1978, 1980). Taking
issue with the micro-level circumscription associated with the explanatory model
approach, Frankenberg (1980) and Singer (1989) argue for the need to locate clinical
events and encounters in the wider field of asymmetrical power relations.

Drawing on dependency and world systems theories, critical medical
anthropology analyzes social processes that bear upon the social distribution of
sickness and access to health care in the context of asymmetrical relations, the role of
the state, the commodification of health care, and the ideological nature of medical
knowledge (e.g., Baer 1982; Singer 1986). Morgan (1987), however, argues that the
application of dependency theory in the analysis of the political economy of health
resulted in a capitalist-centered view of the world. This view is reflected in the

attribution of the configurations of health and health care mainly to the determinative

 

treatment.” [Kleinman 1978:87-88]

6

force of capitalism. Not only is the persistence of indigenous forms of healing in the
midst of capitalism rarely explained but also the local initiative and the active role of
subordinated social actors are ignored.

Others (e. g., Comaroff 1982; Scheper-Hughes and Lock 1986, 1987; Taussig
1980; Young 1978, 1980) begin with the supposition that social life is fundamentally
a negotiation of meanings. They reject the hegemony of positivist science by
regarding Western scientific endeavors as arising from a historical and cultural milieu.
Scheper-Hughes and Lock (1987:48) observe that this theoretical and methodological
persuasion has shifted the focus of inquiry in medical anthropology from "alternative
medical systems" to "the ways in which knowledge relating to the body, health, and
illness is culturally constructed, negotiated, and renegotiated." The same authors
suggest that a task for medical anthropology is

to describe the variety of metaphorical conceptions (conscious and

unconscious) about the body and associated narratives and then to show

the social, political, and individual uses to which conceptions are

applied in practice. [Scheper-Hughes and Lock 1987:49; italics added]
In the same vein, Lindenbaum and Lock (1993:x) assert that the subject matter of
medical anthropology is

neither simply medicine as an institutional body of scientific knowledge

nor the human body as an unproblematic product of nature, but rather

the creation, representation, legitimization, and application of

knowledge about the body in both health and illness.

What is evident in these recent concerns in medical anthropology is the field’s

active involvement in theorizing about the interrelationships among culture, power,

human agency, and history. These are, of course, not isolated developments for they

7
resonate with theoretical musings about ”practice.” Acknowledging the immense
contributions of Bourdieu (1977), de Certeu (1984), Sahlins (1976), Giddens (1979),
and Williams (1977), Ortner (1989b: 199) characterizes practice theories as

[t]heories of the production and transformation of the cultural order

through a variety of forms of action and interaction.... In a practice

analysis one examines the particular forms of human activity and human

relationships prevalent in a society at a given moment, and attempts to

see in them the sources of cultural reproduction and cultural change.

[italics added]

In effect, theories of practice emphasize the inseparability of structure and
human agency, thus rejecting formulations that privilege structure over human agency
or human agency over structure. As Ortner (1989b: 196) notes, Bourdieu’s notion of
habitus refers to "a lived-in and in-lived structure”; Foucault’s idea of discourse
designates "a symbolic order that is controlling yet manipulable"; and Williams’s
concept of hegemony suggests ”a lived system of meaning and values-—constitutive and
constituting. "

This dissertation, thus, aims to contribute to the current discourse on the
interconnectedness of culture, power, and history. It explores the ways in which
power-laden cultural schemas and historical processes shape the struggles against
malaria in the Philippines.

Notes on Malaria Studies in the Philippines

It should be noted, at the outset, that studies of malaria in the Philippines

emphasize an epidemiological approach that leaves the sociocultural underpinnings of

malaria relatively unexplored [see for example the bibliographies by Russell (1934),

Walker (1953), and Rosal (1974)].

8

Studies on the structure, organization, and management of the antimalarial
program in the Philippines come from the field of public administration and, to date,
two studies have been conducted. Doria (1964) examined the process of technical
assistance surrounding malaria eradication in the Philippines. This study documented
the relationship between the Philippine government and donor agencies evident in
activities such as planning, organizing, staffing, directing, coordinating, recording,
and budgeting. The study also described the donor-client relationship inherent in the
program.

Alfiler et al. (1990) examined the organization and management of disease
control programs in the Philippines. Their discussion of malaria control focused on
the shifts in administrative and management strategies in the antimalarial program.
This study prescribed ways to overcome the organizational and administrative
obstacles facing the program in the light of the tenets of public administration. It also
provided useful information for the analysis of the role played by international donors
in the decision-making process concerning the program. Unlike Doria’s study, this
investigation alluded to the dominant role played by international health agencies in
charting the course of the malaria control program in the Philippines.

The studies by Lariosa (1986) and Abaya (1987) are case studies focusing on
the social and cultural aspects of malaria and its control. Lariosa’s inquiry focused
on knowledge, attitudes, and practice (KAP) concerning malaria and its control in
Cabagan, Isabela. The study measured local knowledge about the epidemiology of
malaria and concluded that local notions of malaria etiology, signs and symptoms, and

treatment, in large measure, did not cohere with biomedical knowledge. The

9

investigation also measured the attitudes of the study population towards the health
care delivery system and concluded that the study population held unfavorable
attitudes, particularly in regard to the delivery of health services in the area.

Conducted in the same locale, my inquiry focused on the ecological factors
and ethnomedical knowledge and practices that account for the persistence of malaria.
I characterized the people’s ”medical behavior" as pragmatic, as they used both
"traditional” and "modern" healing practices to ameliorate malaria.

Both studies were partly grounded on the modernity versus tradition paradigm.
In my earlier work, however, I have alluded to the idea that global political and
economic forces (e.g., international health agencies and pharmaceutical industries)
influence the form and content of the local responses to malaria. In this present
study, I am pursuing this point as it relates to the shifts in the orientation of the
malaria program in the Philippines through time.

The social and cultural dimensions of malaria and its control in the Philippines
remain relatively unexplored. Research has been narrowly focused on either the
communities affected by malaria or the state malaria control apparatus. The cultural
politics surrounding the interactions between the state’s antimalarial program and the
malaria-stricken communities has been left virtually unexamined. This study, thus,
addresses these relationships.

Chapter Two provides a description of the research strategies used to conduct
this research. It also includes a discussion of the various representations of Masipi
(the study site) as a social and physical setting.

Chapter Three addresses the key features of the antimalarial program as they

10

unfolded through time. Attention is given to the history of malaria control in the
Philippines. The discussion highlights the roots of the antimalarial campaign in US.
colonial expansion, its grounding in biomedical knowledge and technology, the
primacy it gives to top-down health planning and implementation, and its
embeddedness in the economic and cultural dependency of the Philippines on foreign
aid, notably from the United States.

In Chapter Four, I examine the ways in which malaria assumes its
configuration in the local discourse about the body-in-health and the body-in-
suffering. I focus attention on the local precepts and practices concerning health,
sickness, and healing. My purpose is to describe the ways in which malaria is
configured in the experiential world of the Ilokanos.

Chapter Five focuses attention on the structure and dynamics of the cultural
politics of the antimalarial activities in Masipi. It demonstrates how certain features
of the antimalarial campaign, such as its emphasis on medico-technological strategies
for disease control and its top-down approach to health planning, invariably condition
the cultural politics of the antimalarial interventions in the study area. The analysis
also points to the processes of domination, conformity, and resistance created through
the interactions among the state health functionaries, the state-supervised barangay 6
officials, and the local residents. These interactions reflect the power relations that
shape the nature of negotiations among participants over the official definitions and

strategies concerning malaria control writ large. These encounters illuminate the

 

6The term May is a designation for the smallest politico-geographic unit of the
Philippine state.

11

ways in which the state, employing various strategies of persuasion, contends with
community-based cultural constructions of malaria including the views of the local
residents towards the antimalarial program.

The final chapter underscores the historical and ethnographic grounding of the
cultural politics of the struggles against malaria in the Philippines. It pays heed to the
recent call in the field of medical anthropology for the linking of local to global
processes, especially in regard to the politics of international health. It points out the
processes responsible for the predicaments faced by the state and the Ilokanos in
addressing the problem of malaria. In espousing a notion of power as productive and
transformative, the discussion brings to light the limits of government authority in the

face of locally situated cultural forms of apathy, ambivalence, and resistance.

Chapter Two

METHODS AND RESEARCH SETTING

The first part of this chapter takes up the data gathering methods employed in
this inquiry. The second part discusses the various representations of Masipi, the
setting of the ethnographic investigation.

D h ’ e ’
Historical Research

I focused my historical research on the origin and development of the
antimalarial program in the Philippines. Specifically, I paid attention to the goals that
had guided the efforts to control malaria in the archipelago, efforts that began in the
early 1920s under the US. colonial regime. Primary sources included reports and
other writings by US. nationals who were directly involved in the colonial
government, publications from the Philippine Bureau of Science, and documents such
as memoranda, executive orders, and newsletters from the Philippine Department of
Health and the Malaria Eradication Service (now the Malaria Control Service), and
reports of the periodic external evaluations of the malaria program of the Philippines.
Secondary sources included studies of the malaria program in the Philippines and
works that characterized the nature of Philippine-US relationships from the colonial

and postcolonial era. Library work was conducted in the both the Philippines and the

12

13
United States. In the Philippines, I used the library resources of WHO Western

Pacific Region Office in Manila, the Philippine Department of Health in Manila, the
University of the Philippines Library System in Quezon City, and the Thomas
Jefferson Library in Makati. In the United States, I used the library resources of
Michigan State University in East Lansing, Michigan, and the University of Michigan
in Ann Arbor, Michigan.

Ethnographic Research

I conducted fieldwork in Manila, in the provinces of Cagayan and Isabela in
northeastern Luzon, and in the municipality of Cabagan, Isabela (see Figure 1) from
November 1991 to April 1993. I collected data from health service professionals
(e.g., medical doctors, nurses, midwives, microscopists, sanitary engineers, malaria
workers, and pharmacists), who represented the state health care system, and the
Ilokanos in Masipi, including Kleinman’s ”popular sector"--lay people--and the "folk
sector”--local healers (Kleinman 1978:86).

I carried out some of the research through interviews and observations in
health offices, hospitals, and clinics (see Table 1). When permitted, I tape recorded
the interviews and later transcribed them. Otherwise, I took notes in the process of
interviewing and after leaving the setting.

I spent considerable time with the Ilokanos of Masipi in Cabagan, Isabela.
Masipi, the name of the settlement, means "in between” and characterizes the location
on stretches of land between hills. Masipi’s total land area is 4,733 hectares, and the
elevation ranges from 40 to 140 meters above sea level. Several small tributaries and

intermittent creeks lead to the Masipi Creek, a tributary of the Pinacanauan River.

l4

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15

Table 1. Offices, hospitals, and clinics visited

 

Central Office of the Department of Health in Sta. Cruz, Manila
Regional Health Office (Region II) in Tuguegarao, Cagayan
Provincial Health Office in Ilagan, Isabela

Municipal Health Office in Cabagan, Isabela

Milagros District Hospital in Cabagan, Isabela

Rural Health Unit in Cabagan, Isabela

95".“.‘93‘91‘

 

Two barangays comprise Masipi, with a total population of some 3,000
individuals. Masipi West includes the settlements of Compra and Magallones while
Masipi East includes the settlement of Sagpat. These settlements are separated by
expanses of grasslands and agricultural lands, which are planted in rice, corn,
tobacco, sugarcane, and legumes (see Figure 2).

Figures 3, 4, and 5 reflect the physical features of the three settlements.
Certain climatic and environmental features of the area, as well as aspects of the daily
life in the village, tend to promote a condition conducive to the occurrence and
transmission of malaria. There are abundant water sources (rivers, streams, and man-
made irrigation canals), which are surrounded by thick foliage and undergrowth,
making them suitable breeding places for mosquitoes. Most houses are made of
bamboo and m (coarse grass) thatch and are elevated 3 to 5 feet above
the ground on posts. This leaves no hindrance to mosquito-human contact.

Moreover, as Figure 6 shows, outdoor economic activities take place when malaria
transmission rates and mosquito density are high, at the onset and end of the rainy

season.

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17

 

 

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Figure 6. Outdoor Economic Activities, Malaria Transmission, and Mosquito Density

21

I collected data through participant observation and extended interviews in
various settings such as the sarL-sgi stores (variety stores), where the old and the
young engage in tongtongan (”to converse"); the 21m, where local events such as the
annual pi_s_ta (a religious celebration in honor of a Christian saint), game tournaments,
and drying of palay (unhusked rice) and corn take place; strategic locations along the
river, where most women wash household items and many villagers bathe; the local
chapel, where occasional Roman Catholic masses are held; the barangay hall, where
community assemblies called by the barangay officials are held; the barangay health
station, where encounters between the state-paid midwife and local residents take
place; and in houses of key informants. I also visited households with members
experiencing symptoms of malaria and other afflictions. At times, I was able to
observe healing sessions performed by local healers (mangagas). Finally, I paid close
attention to local discourse concerning the state’s health care services, including its
personnel, and to the encounters between health workers and residents in various
settings.

I also collected data through a survey on people’s views of and experiences
with malaria and the antimalarial program using an interview schedule in Ilokano, the
language of the area. The sample included 30% of 332 heads of household,
distributed across three settlements as shown in Table 2. Interviews took at least an

hour and a half.7

 

7I was assisted by two part-time research assistants, with whom I had worked closely
during my previous fieldwork in the same setting. Both had finished high school.

22

Table 2. Sample population

 

N n
Compra 48 16
Magallones 1 13 34
Sagpat 166 50

Total 332 100

 

N = heads of household
n = sample size

The sample was drawn through a modified random sampling technique. The
selection process started with maps of the settlements showing all the houses, which I
numbered. Pieces of paper were numbered consecutively and randomly selected by
drawing them from a bottle, one at a time and including all pieces of paper for each
drawing (random selection with replacement). At each house that was selected, a
household head was interviewed, either a man or woman depending on who chose to
participate.

There were 52 women and 48 men who participated in the survey. Their ages
ranged from 15 to 60 years old (see Table 3). Most respondents were born in
Cabagan, Isabela, and older participants were born in Bacarra, Ilocos Norte, from
which the early migrants of Masipi originated (see Table 4). Most respondents were

literate and had at least elementary education (see Table 5).

Table 3. Age of respondents

 

Years no.
15-19 2
20-29 20
30-39 33
40-49 17
50-59 16
60 + 12
Total 100

 

Table 4. Birthplace of respondents

 

Location

Masipi

A barangay of Cabagan

A municipality of the
province of Isabela

A municipality in the
province of Ilocos
Norte

Total

no.

50
18

20

12
100

 

24

Table 5. Educational attainment of respondents

 

no.
No formal education 6
Some elementary education 49
Completed elementary education 20
Some high school education 12
Completed high school 10
Some college 3
Total 100

 

Table 6 shows the occupations of the respondents. The category
"housekeeper" indicates a role that is generally ascribed to married women. Women
with this designation also participate in farm work, including planting, harvesting,
processing, and marketing.

It should be noted that I have changed the names and any descriptions of

people in the study to protect their identity.

25

Table 6. Principal occupation of respondents

 

IIO.

Agggimbalay (Housekeeper) 52

Agtalglon (Farmer):
Owner-cultivator8 of ricefield (rf)

Owner-cultivator of upland farm (uf)
Owner-cultivator of rf and uf
Owner-cultivator of rf and
Tenant9 for rf 2
Owner-cultivator of rf and Tenant
for uf 3
Owner-cultivator of rf and Tenant for
rf and uf
Tenant for rf
Tenant for uf
Tenant for rf and uf
Tenant for rf and wage worker10
Mgigntandan (Wage worker):
Farm work
Logging
CAFGU (Military men)“

MNN

:N

r-wos:

SNNUI

Total 1

 

 

i”These are small landowners. Average landholding is 0.5 ha.

91% (share tenancy) is practiced; that is, after all farm inputs such as fertilizers
and seedlings have been deducted from the total cost of the harvest, the tenant gets 70% while
the landlord gets 30%.

10Wage worker refers to a hired agricultural laborer working in tasks such as
ploughing, planting, and harvesting.

”A government-supported paramilitary group called Civilian Armed Forces
Geographical Unit, actively involved in the counterinsurgency program of the state.

26
mm
In this section, I take up the representations of Masipi as gleaned from my

conversations with residents in the poblacign (the center of the municipality of
Cabagan) as well as with those in Masipi. From the former, I generated
characterizations, labelled here as supralocal representations, and the latter,
descriptions glossed as infralocal representations. By delving into these
characterizations of Masipi, I hope to create a local context, a sphere of ideological
forms, as it were, upon which definitions of Masipi as "Other" are predicated. That
local context, it will be shown, reflects the links of Masipi with broader sociopolitical
processes.

Supralocal Representations

Masipi as a may has a relationship to the concept of the barrio, the basic

 

social and territorial entity during the Spanish and US colonial eras. The barangay
was a precolonial settlement and social organization consisting of 500-2000 people,
relatively self-sufficient and kinship-based. Thus, the barangay is a term signifying a
reformulation of a Filipino ideology of mm during the Marcos era. This
move was consistent with the state’s populist discourse. As Aquino (1982) has noted,
the barangay is an instrument for state control.

One key image of Masipi in the minds of outsiders is that it is a W
May (”a very remote or inaccessible bgangay"). It is one of the eastern
ms in the foothill areas of the Sierra Madre mountain range. This image is not
without basis. Masipi is 17 kilometers from the mblacion or m, the seat of the

municipal government. The dirt roads to Masipi are virtually impassable especially

27

during the monsoon months (July to December). Two trucks ply, however
irregularly, from Masipi to either the municipalities of Cabagan or Tumauini. These
trucks are called m, a name probably derived from the fact that these vehicles
were used as ”weapons carriers” during the Second World War. The presence of
these vehicles implies remoteness given their suitability in rugged terrains. In fact,
they are ubiquitous in many so-called "remote W" in the Philippines. This
image of remoteness is also reinforced by the fact that Masipi is one of the points of
entry to huge forest concessions operating in the Sierra Madre mountain range (see
Figure 7; note the Cabagan area in upper left). Logging signifies remoteness simply
because the activity requires penetrating the interiors and exploiting the wilderness.
An equally powerful marker for remoteness is the fact that Masipi does not have
electricity; that is, nagadayo unay, ngigat nga ikgn iti kuryente ("it is so distant that
it is difficult to install electric cables").

Another pervasive image of Masipi is that of a pugad para kadagiti kumunista

or "sanctuary for the communists. The Sierra Madre mountain range is an icon for
the Communist Party of the Philippines, an underground social movement in the
country. Frequently, it figures as a revolutionary symbol in underground protest
songs and other art forms. Located in the foothill areas of the Sierra Madre
mountains, the people in Masipi are branded as either members or supporters of the
CPP, especially the New People’s Army (NPA), its military arm. This image is so
pervasive that I was asked frequently by friends and acquaintances in the pgblacign
whether I had been approached by a member of the NPA, euphemized as "Nice

People Around." Also, in a joking manner I had been branded as an NPA by some

28

 

 

    

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Figure 7. Forest Concessions in the Cagayan Valley

 

 

 

 

 

Source: Department of Environment and Natural Resources (1991)

29
residents in the 292m, having conducted prolonged field work in the area.
Stories abound about the armed clashes between the members of the NPA and
the government military forces that happened very frequently during the late 19705 to
the early 1980s in Isabela and other areas of the Cagayan Valley. Masipi is viewed

as one of those ”battlegrounds. That image still predominates despite the state’s
claim that the CPP has been suffering from organizational and operational reverses
due to internal ideological and leadership squabbles. Two military detachments, one
in the western part and the other in the eastern part, have become permanent
landmarks in Masipi. These detachments are instruments for strict military
surveillance in the whole Province of Isabela and other areas identified by the local
and national mass media as zones containing rebels. Today, their continued presence
is linked with the counterinsurgency measures of the state, a role that has been
recently reinforced by the state’s policy of a total logging ban.12

Meanwhile, state control is also expressed in barangay ordinances requiring
that villagers carry a flashlight in the village at night. The ordinances discourage
clandestine activity and violators are arrested and penalized. Like most militarized
communities in the Philippines, Masipi has a paramilitary unit organized primarily to
enhance counterinsurgency. This unit is called CAFGU (Civilian Armed Forces
Geographical Unit) and its members are recruited from the local populace, under the

supervision of the Philippine National Police.

Another key image is that of an impoverished barangay (marigrigat nga

 

l’“I'his policy was triggered by the Ormoc tragedy (a flash flood that claimed
thousands of lives in Ormoc City, Samar). Deforestation is a major problem in the
Philippines.

30
May). This attribute is linked to the image of inaccessibility discussed earlier.

Outsiders view its remoteness as an obvious constraint faced by the people in
obtaining basic supplies and commodities. Government services include a land reform
program, agricultural extension, and social forestry, which is part of a larger program
on watershed management. These programs are supported by government funds,
acquired through loans from the World Bank. A few weeks before I terminated my
fieldwork in Masipi, gravel was being put on the roads. These developments have
generated strong opinions from the people in the poblacion. Outsiders feel that
Masipi is being favored by the state while equally impoverished barangays
surrounding the pgblacion are being neglected. Some link these efforts to
counterinsurgency schemes, and they insinuate that most employees recruited from the
villages were former members of the underground movement and that their
involvement indicates "their return to the rule of law” and their allegiance to the state.
It may be that the attention to local health services also implies a concern about
people’s welfare and thus serves to consolidate political support for the government.
In the minds of health officials, Masipi and the rest of the Ways located in
the eastern part of Cabagan are "suitable training grounds” for government workers,
particularly those who are assigned the task of doing extension-type services.
Working in these remote areas is seen as a test Of one’s resourcefulness because of
the lack of transportation and potable water; one’s patience because the people of
Masipi are said to be "superstitious" and "mostly illiterate"; and, lastly, one’s courage
because of the counterinsurgency operations in the area.

Masipi and the rest of the eastern MEI—122.115 have acquired the image of

31

11 m lmal ai a , ”that area is malaria-infested." This is not without
basis. From the standpoint of epidemiology (see Figure 8), this area of Cabagan is in
an ecological zone suitable for the normal run of malaria (Abaya 1987; Lariosa 1986).
Masipi is classified under the category ”hard-core” malarious barangay in Cabagan
and has been one of the targets of antimalarial operations. In short, Masipi is almost
always implicated in discussions concerning the loci of malaria in Isabela in general
and Cabagan in particular.
Infralocal Representations

One gains access to the realm of infralocal representations from local narrative
history. That narrative history is inscribed in stories of My (elderly men) and
mm (elderly women). These stories reinforce Fonacier’s (1953) essay about the
migration of Ilokanos from their Ilocos homeland because of extreme land pressure.
Fonacier refers to this migration as the ”great Ilokano movement." He writes:

legion of hardy pioneers left their ancestral abodes and staked
their fortunes elsewhere. The story is told by the land that these
pioneers had placed under cultivation--land that is mute but eloquent
testimony of the labors and sacrifices of these pioneers.... The story is
a saga of a people who were pioneers, a people who finding themselves
hemmed in within the narrow confines of their ancestral homes
expanded, colonized, and settled in other areas more suited to their
spirit [pp. 89-90]

The Ilokanos went to the Cagayan Valley and settled in regions now
known as the provinces of Cagayan, Isabela and Nueva Vizcaya. This
is to be expected because that region is adjacent to the Ilokos coastal
plain and through the passes of the Cordillera or by sailing vessels
doubling Cape Bejeador, settlers could easily reach the Cagayan Valley
region where a big expanse of rich and fertile land awaited the thrifty
and industrious Ilokanos. They also went south to Pangasinan,
particularly eastern Pangasinan which is adjacent to the province of La
Union. Then they moved into Tarlac, Zambales and Nueva Ecija, and

    

CAGAYAN VALLEY

n extent of malaria
- hard-core arms

Figure 8. Distribution of Malaria in the Philippines
Source: Cabrera and Arambulo (1977)

33

occupied the vast stretches of land in those regions [pp. 92-93]13

The memories of Lakay Pedro, a resident of Masipi, now in his late 80s,
complement Fonacier’s remarks about the llokanization of the Cagayan Valley and
parts of the central plains of Luzon. Lakay Pedro was six years old when they (his
parents and four brothers and one sister) moved to Isabela from Bacarra, Ilocos
Norte, because land for cultivation was scarce. Their life was ”full of hardships"
because they were "poor." Two of his uncles and their families had earlier settled
and cultivated the lands in Masipi. He recalled: "The path then was a small trail with
elevated lands on both sides (flat) so perhaps this is why this whole vast place is
called Masipi.” His uncles were periodically visited by Lakay Frogoso and Lakay
Rambac because his uncles were also working for these two landowners, who lived in
the m. He said that the eastern part of Masipi is called Sagpat (”tableland”)
and it is an older community, settled by the Rambacs, Acobs, Acsons, and Subias.
These families all originated from Bacarra and had been able to acquire their own
farm lands. They built an irrigation canal and organized themselves into a corporate

group or sangiera." The western part is called Magallones since it was the pamilia iti

 

13In the same vein, Keesing (1962: 181) writes that

[fjrom 1850 to 1857, Ilocanos were given free passages,
advances of money, and other inducements to settle as tobacco
growers [by the Spanish authorities], augmenting the local
population... The first American census showed 50,401
Ilocanos... By 1948, llocanization of the Cagayan provinces
had progressed to a point where 435,519 persons counted
Iloko as their mother tongue, or approximately two-thirds of
their total population of 638,301.

1“Lewis (1971) provides a description of the structure and function of the sanjeras or
corporate irrigation societies in the provinces of Ilokos Norte and Isabela.

34
Mm (”Magallones family") that opened the area. And sfiig Compra (”to buy")

is part of Magallones. Its name was derived from the fact that the residents, who
were formerly residing in Sagpat and Magallones, bought their residential lots from a
particular landlord.

Lakay Pedro spoke of the close social ties among the people of Masipi. He
recalled that ”during the olden days” they practiced ammoyo:

That’s working together as a group. When there was a house to be

built, we did it as a group. We were not paid, we just did it through

ammgyo. We had to clear lands for farming and we also did it through

ammoyo. We took turns clearing the lands of each member.
With a bit of sarcasm, Lakay Pedro lamented the gradual erosion of the institution of
ammgyg:

I don’t know, perhaps the young generation is too intelligent and

hardheaded. Before, when a leader says this or that, the members

follow. Now, this is no longer true. People today can be likened to

scattered termites. Money moves everything these days. That’s the

trait of today.

According to oral history, Masipi as a territorial unit is composed of Sagpat,
Magallones, and Compra. It was only in the early 19805 that Masipi was divided into
two barangay, namely, Masipi East and Masipi West, which is now officially
composed of three s_i_tjo, namely, Magallones, Compra and Guingab.” The residents
of Magallones and Compra, however, have affinal, consanguineal, and fictive kinship
ties as well as a shared history that lead them to regard Guingab’s residents as

different (sabali isuda—-"they are different"). This social distance is reinforced by the

fact that Guingab residents are Ibanag speakers and also by their physical distance

 

1‘I learned from some bargngay officials that Guingab was merged with Magallones
and Compra to meet the population size required to establish a barangay.

35

(Guingab is about 1.5 kilometers from Magallones and Compra).

From the mid-19603 until the early 1970s, Sagpat experienced tremendous
instability created by the abuses committed by private armies of local landlords and
politicians called 111m. The M were extremely dreaded by the local
populace. They abused women, pilfered property such as agricultural produce and
farm animals, and extorted cash from the local inhabitants. At the same time, the
Communist Party of the Philippines was increasingly gaining support from many
communities in the countryside. It should be underscored here that, according to
many villagers, the NPA took the side of the local peasants and protected them from
the abuses of the _tu_lis_anes. Armed clashes were said to be recurrent. Masipi became
one of the NPA "outposts" in Cagayan Valley and at the same time a target for
military operations by the government forces. There was great pressure from the
state for the residents of Sagpat to move to Magallones and Compra, which were
about two and a half kilometers away, apparently because the residents were being
caught in the middle. The situation started to stabilize by the late 19708, with the
presence of the two military outposts in the area. Parenthetically, the martial law
regime in the Philippines under Marcos spanned 10 years (1972-1982). Meanwhile,
the people of Masipi regard this period of their history, which they call panagn ti
_N_13_A (time of the NPA), as a time of fear, instability, and adventure.

Notwithstanding the changes in the residential patterns in Masipi brought about
by this experience, the idiom of kinship relations or W dominates the
organization of social life in Masipi. The notion of Maggy has become a shared

idiom among the residents of Masipi. They identify and associate themselves with the

36

hmgay as a both a territorial and social unit, signifying local collective interests, on
the one hand, and a political-administrative unit that articulates the interests of the
state, on the other. In concrete terms, the residents of Masipi invoke their being
Way—Masipi ("from bargngay Masipi”) to assert their identity as members of
the same sociopolitical unit. This stance is particularly evident when people
participate in social events such as the town’s annual foundation day celebration,
during which their sense of ”community" is asserted in relation to the other W
in Cabagan. Residents of Masipi also hold their own annual mg (a community-wide
celebration in honor of their patron saint, San Isidro, a Roman Catholic saint). The
pi_sta is a powerful marker of their existence as a sociopolitical entity. During social
events such as this, the links of Masipi with the agencies of the state take on concrete
expression. For instance, it has become customary for high-ranking government
officials, military men, and members of the local municipal elite to be invited to the
occasion and, consequently, reinforce publicly not only the prevailing patron-client
ties but also the social differentiation in Masipi. The few W (”wealthy”) are
afforded the chance to have their status validated, especially in the eyes of the
kalkalaingan (”people of moderate means,” that is, able to maintain adequate
subsistence) and the napanglaw ("poor" or "marginal"), by giving lavish feasts,
attended by the elite of Cabagan. There is, therefore, a tacit recognition of the three
aforementioned social positions as the local status model, which broadly correspond to
land—owners WW3), tenants (filmy and laborers (ma_ki_tzmd_an_),
respectively.

The pig, like election campaigns, is an occasion in which the images of

37

Masipi become part of a political idiom couched in terms of the patronage politics that
characterize Philippine politics today (cf. Kerkvliet 1990). It is during these
occasions that such supralocal images as "remoteness and inaccessibility due to bad
roads,” "absence of electricity," ”poor health conditions,” ”lack of potable water,”
and "impoverished" are shared by the residents themselves. These images are
invoked by the state-paid W officials and other influential members of the
community to generate attention and support from the municipal government as their
link to the state bureaucracy. The appropriation, of course, is a two-way process for
the same idioms are employed to couch certain promises and commitments in regard
to the well-being of the people of Masipi, especially during elections and other
political campaigns.

From the preceding discussion, one can deduce that the creation of Masipi as a
m reflects the ongoing relationship between the people of Masipi and the state
through its governmental agencies. As will be shown in Chapters Four and Five, that
relationship is made concrete through the process of implementation of state programs
in Masipi. That process finds its specific expression in the cultural politics
surrounding the interactions between the state’s health care system and the social and

cultural spheres of everyday life among the Ilokanos of Masipi.

Chapter Three

THE PHILIPPINE ANTIMALARIAL PROGRAM THROUGH TINIE

Along with other so-called tropical diseases,“ such as cholera, leprosy, and
tuberculosis, malaria became the target of public health campaigns in the Philippines
during the early part of this century under the U.S. colonial administration. This
chapter examines the history of antimalarial efforts in the Philippines. My purpose
here is to consider the key features of the antimalarial program and to provide an
understanding of how history has shaped the structure and dynamics of the program.
These interconnected features include the national-international health and
development agenda, top-down health planning and implementation, and a well-
entrenched epidemiological orientation of disease control interventions that fails to
consider the relevance of local knowledge and practice in disease control efforts.

I focus on the orientation of the malaria control program. The analysis
suggests that military, economic, and political goals are linked to the development of
the antimalarial program in the Philippines.

I contend that the antimalarial schema is part and parcel of a health care

 

16Contrary to common understanding, cholera, plague, leprosy, smallpox, typhoid,
tuberculosis and many intestinal parasites are not necessarily bound up with tropical
conditions in the geographic and climatic sense. These diseases have all thrived in western
Europe and the United States. The term tropical diseases can thus be viewed as a misnomer
(cf. Doyal 1979:100).

38

39

system that rests upon the authoritative knowledge and practice of biomedicine and
epidemiology. This orientation justifies professional dominance in the planning and
implementation of antimalarial activities. Local precepts and practices frequently run
counter to the tenets of Western science, thus the colonial and current medical
discourse tend to relegate them to the realm of superstitions and irrationality.
Antimalarial campaigns, thus, have tended to assume that it is possible to reorient
people’s ideas and behavior towards biomedical knowledge and practice.

In addition, this chapter shows that the antimalarial program relies heavily
upon external financial and technical assistance. This situation is perpetuated through
the patron-client relationship of the Philippines with the United States through the
United States Agency for International Development and other international agencies
such as the Rockefeller Foundation, World Health Organization, and World Bank.

The following exposition deals with three broad temporal contexts, namely, the
American Colonial Administration (1898-1935), the Transition to Independence or the

Commonwealth (1936-1946), and the Post-Colonial Period (1946-1993).

The American Colgnial Administration (1828-1235):
"km ° gs of the Bagla Agaju Malaria"

The immense attention given by the U.S. colonial government to so-called
"tropical diseases,” such as malaria, leprosy, and cholera can be said to be rooted in
European colonization of Asia and Africa. Campaigns against tropical diseases were
initiated in England in the late 19th century and led to the founding of schools of
tropical medicine in Liverpool and London. This development in tropical health and

medicine was to provide further impetus for confronting public health problems

4o

hampering the process of colonization. Elliot17 (1917: 184) expressed this cogently:

The American occupation of the Philippines, Cuba and Porto Rico [sic]
came at a time when the study of the diseases peculiar to the tropics
was engaging the serious attention of governments as well as the
medical profession. Recent discoveries had suggested the possibility
that cholera, plague, yellow fever and malaria might not only be
controlled, but almost, if not entirely, prevented and the tropics made
safe places of residence for white men. The possibility of saving the
thousands of lives which were being destroyed by these dread diseases
appealed strongly to the humanitarian instincts of the world. [italics
added]

Thus, not only was tropical disease control tied to the motive of making the
tropics safe for white men’s habitation. It also served as an idiom for justifying U.S.
”benevolent assimilation” of the Philippines ("The possibility of saving the thousands
of lives which were being destroyed by these dread diseases appealed strongly to the
humanitarian instincts of the world").

Using their own standards for health and sanitation, the American colonial
administrators laid the blame for the poor health conditions on the Spanish colonial
regime. For instance, Worcester18 (1914) described the health conditions in the
Philippines as "shocking in the extreme”:

I had the abundant opportunity to observe health conditions in the

Philippines during the Spanish regime.... There were no provisions for

the sanitary disposal of human waste even in Manila. If one had

occasion to be out on foot at night, it was wise to keep in the middle to
the street and still wiser to carry raised umbrella. [p. 329]

 

1“’Charles Burke Elliot was a member of the United States Philippine Commission,
Secretary of Commerce and Police in the Government of the Philippines, Associate Justice of
the Supreme Court of the Philippines, and Associate Justice of the Supreme Court of
Minnesota.

18Dean Worcester was the Secretary of the Interior of the Philippine Islands from
1901-1913 and was a member of the U.S. Philippine Commission from 1900-1913.

41

Conditions in the provinces were proportionately worse. As a rule
there was no evidence of any effort to put provincial towns into decent
sanitary conditions. [p. 329]

Elliot (1917: 186) further discredited the Spaniards and the Filipinos by
deploring their ”unsanitary practices” as well as their adherence to "superstitions. "
Specifically taking up the case of malaria, he wrote:

The Filipinos realized nothing of the importance of sanitation and the
Spanish officials paid little attention to such matters.... Superstition had
much to do with the way in which both Spaniards and Filipinos lived.
The belief that the night air contained some poisonous miasma
productive of malarial fever prevailed generally and the natives closed
both doors and windows to exclude the among, the devil spirits which
flew abroad only at night.

Accusations of ignorance of the Filipinos about "proper hygiene" and "modern
medicine” punctuated the colonial discourse. The absence of laws to address
"sanitation,” defined in terms of the colonialist’s standards, was also invoked. The
claims of Elliot (1917:186) exemplify this "tradition versus modernity” mode of
thinking:

That efficient ally of the sanitarian, cold weather, was unknown.
Bacteria and parasites flourished throughout the year. The alternating
heat and moisture bred mosquitoes and other insects innumerable.
Where science, skill and well directed energy so badly needed were all
unknown...

Cholera, the plague, malaria, beri-beri and other diseases killed
vast numbers and the people in their ignorance and blindness continued
the very things which were most certain to bring death. They drank
water from the streams in which they and their work animals bathed
and from shallow open wells into which streets and cemeteries drained.
Artesian wells were unknown.... [italics added]

There were no food laws, no animal inspection, no proper
slaughter houses, and the numerous markets were filthy beyond
description. Fruit and provisions were commonly sold from the ground
and, covered with dust and dirt, were eaten without being washed or
cooked....

42

It was not uncommon for a half a dozen persons to sleep in a

room measuring six by eight feet, with all the doors and windows

securely closed against the imaginary night-flying spirits, in blissful

disregard of the millions of very real microbes in their midst. [italics

added]

While taking a stance of "blaming the victim," the U.S. colonial administrators
also took a ”compassionate” tack. This political posturing is clearly expressed by
Worcester (1914:329-330):

Everywhere I saw people dying of curable ailments. Malaria was

prevalent in many regions in which it was impossible to secure good

quinine. The stuff on sale consisted largely of cornstarch, or plaster of

Paris. Fortunately, we had brought with us from the United States a

great quantity of quinine and we made friends with the Filipinos in

many a town by giving this drug gratis to their sick.

In a sense, the malaria problem provided the opportunity for the Americans to win the
hearts of the Filipinos (”... we made friends with the Filipinos in many a town”).

As early as August 17, 1899, Dr. Hoyt, major and chief Surgeon of U.S.
Volunteers, suggested the establishment of a central and general department of health
in the Philippine colony. Two years later, a Bureau of Health was created. Under
the Taft Commission, Dean Worcester, in his capacity as Secretary of Interior,
attached the Bureau of Health to the Department of Interior. For wider nationwide
public health campaigns Provincial Health Boards were also created (Tiglao 1975 :7).

Legislation was drafted by the Insular Board of Health and approved by the
Philippine Commission (see Table 7). It could be said, thus, that public health
initiatives became a centerpiece of the U.S. colonial administration in building an

image of a benevolent colonial state. At the same time, these initiatives marked the

top-down approach to health planning.

43

Table 7. Health-related legislation promulgated during the early U.S. occupation

 

10. Act No. 1760

Legislation

. Act No.

Act No.

. Act No.

Act No.

Act No.

Act No.

7. Act No.
8.
9. Act No.

Act No.

187
307
308
309
3 10
490
593

595
1711

Purpose

An act transferring the employees of the Board of Health of the
City of Manila to the Insular Board of Health.

An act providing for the establishment of the provincial board of
health and fixing their powers and duties.

An act providing for the establishment of the municipal boards
of health.

An act providing the compulsory vaccination of inhabitants of
the Philippines.

An act regulating the practice of medicine and surgery in the
Philippines.

An act appropriating $50,000 for the establishment of a leper
colony in Culion.

An act regulating the practice of dentistry.

An act regulating the practice of pharmacy.

An act providing for the control and suppression of leprosy in
the Philippine Islands.

An act providing for the internment or burning of the bodies of
animals which died from rinderpest and prohibiting the sale or
use of any part thereof.

 

Source: Tiglao (1975:9)

44
Russell19 (1934) noted that in 1911, the Bureau of Health surveyed San Jose,

Mindoro, known as the "white man’s grave," because of its extreme malarious
condition. The Bureau focused on this area because malaria had inhibited
development of its fertile soil by Europeans and Americans. Control measures
included drainage, clearing vegetation, screening doors and windows, dumping oil on
stagnant water, and quinine prophylaxis.

Indeed, the colonial administrators were forthright in disclosing the link
between public health and their commercial and economic agenda. Worcester
contended that the ”deplorable sanitary and health condition" represented a "major
obstacle in the development of the great resources of this remarkable country”
(Worcester 1914:67). Heiser20 concurred and remarked that "as long as the Oriental
was allowed to remain disease ridden, he was a constant threat to the Occidental who
clung to the idea that he could keep himself healthy in a small disease-ringed circle. "
He also stressed the idea that "colonial labor had a direct monetary value"
(1936:37). Not surprisingly, some scholars of Philippine history (e.g., Agoncillo
and Alfonso 1967; Constantino 1967) are in agreement that the U.S. regarded the
Philippines not only as an economic asset but also as a strategic asset in gaining

entrance to the China market.

 

l9Paul Russell was formerly chief of the program of Malaria Investigations, Bureau of
Science, Manila, which was partly supported by the International Health Division of the
Rockefeller Foundation. He was actively involved in studies on the epidemiology of malaria
in the Philippines in the early thirties.

20Dr. Victor Heiser served as Chief Quarantine Officer for the Philippine Islands; as
Chief of the Bureau of Health under the office of Dean Worcester, the Secretary of Interior;
and as the chief officer of the International Health Board for the Far East of the Rockefeller
Foundation.

45

Antimalarial activities were, until 1926 when the Malaria Control Section was
created in the Bureau of Health, confined to U.S. military camps. Stagnant pools
were drained and covered with oil, and underbrush was cleared. Preventive measures
such as the use of mosquito nets also became mandatory. Men in the Lucena
barracks, for example, were court-martialed for not using their mosquito nets properly
(Page 1906, cited in Russell 1934:13).

At the same time, the U.S. Army was engaged in scientific research on
malaria, in line with the development of control strategies. For instance, Walker and
Barber (1914), both members of the U.S. military corps of scientists, called attention
to the mounting evidence that the malaria] mosquito in the Philippines breeds in
streams, negating the classical view of ”stagnant water” as the breeding place for the
anopheline mosquito vectors. Thus, the military was not only engaged in research but
also actively involved in the initiation of environmental interventions to control
malaria.

The antimalarial schema is one that can be characterized as mosquito-centric.
This feature of the schema is expressed in the discourse among the colonial
administrators. The following conversation between Heiser and Military Governor
Leonard Wood culled from Heiser (1936:451—452) is a telling example:

In spite of all our attempts at control, the problem was by no means

near a solution. The campaign was given new impetus when I returned

to the Islands in 1921. One evening after dinner Governor General

Wood and I were sitting, as was our custom, on the veranda of

Malacanang.

”I’ve a very pleasant surprise for you," the General said, "I’ve secured

a million dollars for you to spend on malaria. According to the health
reports, thirty thousand people are dying annually from it, and it’s time

46

we wiped it out. "

”General," I replied, ”I wouldn’t know how to spend as much as that
productively. From what I’ve learned about mosquitoes, the mere
expenditure of money won’t help toward the solution. "

”Why not? That’s the way we did it in Panama."

”But they never had to sanitate more than a few square miles in the
Canal Zone while we have thousands. "

”Of course you can get rid of it if you’ll drain the swamps. That will
cut malaria down right away. "

”But, General, we’re running into all sorts of contradictions in the
study of malaria. Isn’t it possible that swamps may not be responsible
for malaria here?”

"They have everywhere else. Why not here?"
”Nobody’s proved it, and it’s not a scientific way of finding out."

"Well, that’s the way I want it done!” was General Woods’s categorical
response.

I considered that the General, himself a medical man, should not
have taken such an attitude. "In that case, General, I’d better stop,” I
said. "I can’t proceed that way. It won’t be difficult for you to find
someone to work on the problem as you may direct, and your method
may be right. I hope it is."

The subject was dropped on this uncompromising note. But the
next morning, after a good night’s sleep, the General, as was his wont,
repented his gruffness and was extremely apologetic. ”What do I know
about malaria? Forget everything I said, and tell me your ideas.”

”In the first place, I’d like to know whether all the deaths ascribed to
malaria are really due to that cause. And, if they are, I’d like to find
out why all the measures we’ve taken in the malarial districts have so
far been practically ineffective. I suggest asking the International
Health Board for help in getting a good malariologist here to make a
survey."

Wood agreed to this program without a moment’s hesitation and
as soon as possible Walter D. Tiedeman was brought to the Islands.

47

He selected four towns, each representing a geographical type--one hill

town, one lowland, one bordering a lake, and one lake village

influenced by running water from nearby hillsides.

True to his orientation as a medical doctor, Heiser pushed for further scientific
studies to be conducted to understand the malaria problem in the Philippines. He
insisted on the need to invite the International Health Board of the Rockefeller
Foundation to look into the problem.

In 1921, by an invitation extended by Military Governor Leonard Wood, the
Rockefeller Foundation, through its International Health Division, became actively
involved in malaria studies in the Philippines. By 1924, several epidemiological
surveys were completed by the Rockefeller Foundation, in cooperation with U.S.
military medical and engineering corps. Subsequently, the Rockefeller Foundation
and the Bureau of Health carried out control demonstrations in the country.

The Rockefeller Foundation concluded that although malaria was widespread
throughout the archipelago, it was less deadly than previously thought. The
Foundation recommended that it could be effectively controlled through Paris Green,
a larvicide. Hospitalization costs were ten times greater than actual measures to
prevent cases of malaria. Concurring with the Bureau of Health, the Foundation
regarded free quinine distribution through the municipal treasurers merely palliative
and emphasized the importance of controlling the breeding places of mosquitoes
(Russell 1933).

It is important to stress, however, that the health-related activities of the

Rockefeller Foundation should not be viewed solely as advancing scientific research

and humanitarian concerns. In this regard, Brown (1976) observes that a close link

48

exists between U.S. colonialism and the Foundation’s activities in Asia and Latin
America. He writes:

The Rockefeller programs did not concern themselves with workers’

physical productivity alone. They were also intended to reduce cultural

resistance of ”backward" and "uncivilized peoples" to the domination of

their lives and society by industrial capitalism. Whether in the jungles

of Latin America or the isolated islands of the Philippines, the

Rockefeller Foundation discovered what the missionaries before them

understood: that medicine was almost an irresistible force in the

colonization of non-industrialized countries. [Brown 1976:900]

In other words, the humanitarian-cum-scientific motive of the Rockefeller Foundation
in engaging in public health campaigns in the country served important functions in
the image-building and influence-promoting efforts of the U.S. in the Philippines and
worldwide.

At this point, it could be suggested that the concern over the malaria problem
took root in the U.S. colonial public health initiatives, which were predicated on the
fact that malaria, among other diseases, hindered U.S. commercial, economic, and
military goals. These motives provided the impetus for state-led, centrally organized
antimalarial efforts. In addition, "victim-blaming” became a prominent aspect of the
colonial discourse on public health conditions in the country simply because, from the

point of view of the colonial administrators, the Filipinos’ sense of health and well-

being did not conform with Western standards of medicine and public health.

Thg Commgnwealth Perig (1235-1245):
" a Qampaaga’ Deterioratg"

As a transition from a colonial to an independent state, a Philippine
Commonwealth Government was established for the Philippines. During this

transition period little funding was provided for the malaria program. As World War

49

II loomed, priority was given to the military in the government budget at the expense
of social services such as public health.

The war years were an extremely difficult time for the state to deal with public
health concerns. The chaotic military regime of the Japanese created an atmosphere
of instability in the country. Evacuation from and return to malarious regions and the
movement of U.S. military forces led to a marked increase in malaria. It became
prevalent not only in known malarious areas but also in places that had previously
been nonmalarious (Tiglao 1975). Movement of population exacerbated health
problems especially in terms of malaria control. As a result, the advances gained in
the antimalarial campaigns prior to World War II deteriorated.

Around 1940, however, DDT (Dichloro-diphenyl-trichloroethane) was
discovered. DDT was first synthesized by Ziedler in Germany in 1934, but the
insecticidal properties were discovered by Paul Muller of JR. Geigy A.G.,
Switzerland, in 1936-37. This compound was first applied in 1943 by the British
Ministry of Supply. Further development and mass production ensued in the U.S.
and UK. DDT affects insects as a contact and stomach poison and has a residual
killing effect when sprayed on surfaces upon which insects walk or rest, as first noted
with house flies by Weismann in Switzerland in 1942, and with mosquitoes by
personnel of the Orlando Laboratory in the U.S. Bureau of Entomology in 1943
(Russell 1952:137). This technology for disease control was to become an integral

part of the Philippine antimalarial schema after the war.

50

The Post- oloni [Period 19 49905:
" hi from on r l o Eradica ion Contr 1"

The post-World War II Philippines was in extreme political, social and
economic crisis brought about by the war. The aftermath of the Second World War
saw the emergence of the United States as a politically and economically powerful
nation. Peripheral economies came to rely upon the U.S. for support and aid to
rehabilitate those countries devastated by the war.

The rehabilitation of the Philippines became the order of the day. The United
States government, under U.S. Public Health Law No. 370 of the 79th Congress,

generally cited as the Philippine Rehabilitation Act of 194621 provided an outlay of $6

 

21Cited here are provisions embodied in the Act (quoted in Tiglao 1975:98-99):

Section 505, Title III of the Philippine Rehabilitation Act of 1946 delineated
the authority given to the United States Public Health Service in the
rehabilitation of the Philippine public health system. It reads as follows:

Section 305 (a) The Public Health Service of the Federal Security Agency is
authorized to cooperate with the government of the Philippines (Republic of
the Philippines), and with other appropriate agencies or organizations, in the
rehabilitation and development of public health services and facilities
throughout the Philippines.

Section 305 (b) To accomplish such purposes the Public Health Service shall
at the earliest practicable time, survey the health situation in the Philippines,
and is authorized to replace, expand, or install such health services and
facilities in the Philippines as deemed essential to the preservation of health,
and may assist in the rehabilitation and development of a Philippine quarantine
service for prevention of introduction of disease from abroad or from one
island to another. The Public Health Service may set up demonstrations and
establish training centers in the Philippines; may establish and maintain in the
Philippines a school or schools for the purpose of providing practical
instruction in public health; and may, at any time prior to January 1, 1948,
provide one year of training in appropriate schools or colleges in the United
States to not more than one hundred Filipinos, to be designated by the
President of the Philippines subject to the provisions of Section 311, (c) in
public health methods and administration. It may replace equipment and
supply reasonably necessary additional equipment, utilizing for this purpose,
so far as possible, surplus property, and may recommend to the commission

51

million. In return, rights were given to U.S. citizens to exploit the country’s natural
resources. Also involved in the rehabilitation process were the Philippine Civil
Affairs Agency of the Army of Liberation, the U.S. Mutual Security Agency,22 the
United Nations International Children’s Emergency Funds, and the World Health
Organization (WHO). WHO has been assisting member states with malaria control
ever since its founding in 1948.

As Figure 9 shows, malaria control was reinstated as a key goal in the
U.S.-directed Philippine Public Health Rehabilitation Program. Again, a complex
bureaucracy was involved, notably the close supervision of the U.S. Public Health
Service over the public health programs in the country.

The Philippine Public Health Rehabilitation Program also included the control
of communicable diseases such as tuberculosis, venereal diseases, leprosy; general
sanitation; maternal-child health, nutrition; health education; public health training
centers; the rehabilitation of laboratories essential to public health; and the

rehabilitation of the Philippine Quarantine Service.

 

the repair or construction under the provisions of Section 304, at any time
prior to July 1, 1950, of buildings deemed essential to the rehabilitation of
public health and quarantine functions.

22This U.S. government agency was formerly called Economic Cooperation Agency
(ECA). Then it became Foreign Operations Administration, then International Cooperation
Administration (ICA), and presently, the U.S. Agency for International Development
(USAID).

52

Philippine Public Health Rehabilitation Program

 

 

U.S. Public Health Service
Headquarters, Washington. DC.

 

 

l

 

 

Bureau of State Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Washington, DC.
j
Headquarters U.S.P.H.S. for Far East
. Assistant Surgeon General in Charge , , ,
”m“ 513‘?”me (Adviser to the Pres. of the Philippines on 00‘" U-S- Rehabillmm
( 'm 9 Pub. Health. Quarantine, Executive Office Mew“
Director of Field Operation)
I
Ex ‘I Off I I
ecutive icer
. . . Consultant . -
Admrnistrative Office . . . . Director of Field Operations
Joint Services 0“" ”m“ D‘V“'°“ (Act: also as Consultant on MCI-l a Nutrition Ham
Education. Lab. Rehabilitation Centers) Liaison
f I J marinara? titre
General . Fm“ Liaison Work and aid “affair.“ Health Ofleicer. 0!;th
Administrative ' in Rehabilitation Director ofthe Bureau of Health. Direeroror
of Bureau of Quarantine "“9"“. ”W “W
I E Service under Secretary
Personnel Propcny Of Health
and and
Payroll Supply
r see next page—b
Communion “e“ 5‘19“"? . Preventive Pediatrics]
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1 DIVISIOI'I Clinic)
I Executive Assistant]
1 I National Pub. Health
- - - - - Laborato Rehabilitation 20 Mobile Surv
Immvd alarm... or... °’
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and he“! Laboratory Rehabilitation " Corrective Units
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20 Mobile Malaria — "wgfigffm
Um“ Field Supervision, MCH
[ m J 1 1 and —
. . Nutrition Division 4 Mobile Health
i SM [WEI [Control i i Education i L Education Units

 

 

 

 

 

Figure 9. Organizational Structure of the Philippine Public Health Rehabilitation Program
Source: Tiglao (1975)

 

53

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

continuation
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W Officer m Charge fl Medical Officer in Charge
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Mm Officer “1 e LI _ Medical Oflicer in Charge
Installation of Chlorination
9 San. water Analysis Um" ,
Station. Sanitary Surveys Exam. of Food and Drinks

 

 

Figure 9. (continued)

 

 

 

 

54

Various activities conducted with respect to malaria control are shown in Table
8. Every effort was made to impress on the public the nature of malaria, its dangers,
methods for its prevention and control, and its overall effect on national economic
recovery. These activities were accomplished through lectures to and conferences
with medical societies, hospital personnel and private practitioners; malaria
educational campaigns in schools, dispensaries, public meetings, theaters, town
fiestas, and in house-to-house surveys; participation in fairs, expositions, and other
local festivals; distribution of posters and printed malaria information to schools, civic
organizations and the general public; and the use of moving pictures and press
releases (Tiglao 1975:102).

The 1950s saw, as a result of the survey carried out by the U.S. Economic
Survey Mission, better known as the Bell Trade Mission, greater involvement of the
U.S. in Philippine affairs (Bell 1950). The mission underscored such problems as
low productivity, increased insurgency, and a generally demoralized populace.
Export quotas, as stipulated in the Bell Trade Act, could not be met. The left—wing
Hukbalahap Movement, otherwise known as Hukbong Mapagpalayang Bayan, had
gathered enough strength to threaten the stability of the administration. The people
lacked faith in the corruption-ridden government of President Quirino. These were
the conclusions found in the Bell Mission Report and they became the basis for U.S.
aid under the Quirino-Foster Agreement.

The Bell Mission Report became the White Paper that guided American
interventions in the Philippines. These interventions covered a broad range of

economic reforms that would have significant influence over the Philippine

55

Table 8. Malaria control and related activities during the rehabilitation period

(1946—1950)

 

A. Control Activities

B. Training

C. Research

D. Health Campaigns

E. Special Projects

20 malaria control units collected information on malaria
endemicity, topography, meteorology, demography, and
socioeconomic status of malarious areas; provided free
treatment of malaria patients in dispensaries and those
that are encountered in the house-to-house visits;
conducted control activities such as clearing brush from
stream banks, Iarviciding, river straightening, filling and
subsoil drainage, and spraying of DDT through hand and
power sprayers and airplanes

Training of malariologists, entomologists, malaria
engineers, and technicians

On the effectiveness of Iarvicides, antimalarials, vector
control methods, and other pertinent aspects of
malariology. Among the projects undertaken were
a. DDT-treated sawdust as a larvicide
b. DDT residual spraying of houses
c. antimalarial drugs against strains of human
malaria e. g., chloroquine and
chloroguanide
d. malaria plasmodia in anophelines other than
A. minimus flavirostris
e. the use of DDT-thermal aerosol

Mass education through public meetings and film
presentations

Malaria control projects in Negros, a key sugar
producing area in the Visayan Islands and in Quezon
City, site of many governmental institutions; educational
demonstrations in selected schools; technical supervision
of mosquito control at the International Airport

 

56
government’s domestic affairs. The internal problem of Huk insurgency became the
government’s goal addressed by Quirino’s Secretary of Defense, Ramon Magsaysay,
with the assistance of the U.S.-supported JUSMAG (Joint U.S.-Philippine Military
Advisory Group).

Along with the containment of insurgency was intensified agricultural
development. Two studies funded by the International Cooperation Administration
(ICA) and the Philippine Council for United States Aid, namely, the Rivera-
MacMillan Report (1952), entitled ”The Rural Philippines," and the Hardie Report
(1952), entitled ”Philippine land Tenure Reform," revealed that agricultural
development was the main thrust of the U.S. policy in the Philippines. This thrust
was also entirely consistent with the global economic interests of the United States.

In the health field, the Bell Trade Act contended that unless public health
service was restored to a high degree of efficiency, the development of rural areas
would be handicapped. As to the malaria situation, the Department of Health and
ICA noted that in 1953

[o]ne-tenth of the [nation’s] population was ill with malaria, and of the

2,000,000 annual cases, some 10,000 resulted in death. Malaria was

most prevalent in rural areas and imposed a heavy burden upon the 3/4

of the population engaged in agricultural work. The annual economic

losses from malaria were variously estimated to be 120 to 500

million pesos annually. [cited in Doria 1964:18]

As part of world diplomacy, international aid began to pour into the country.
This period was aptly called the "advent of bilateral and multilateral assistance" or, in

the words of Dr. R. Padua, then Undersecretary of Health, ”the golden era of public

health” in the Philippines (Tiglao 1975:125). The various agencies involved in

57

public-health related programs in the country in 1953 are listed in Table 9.

Table 9. Bilateral and multilateral foreign aid agencies and private foundations

 

U.S. government agency:

Economic Cooperation Administration (now USAID)

U.S,-based foundatioaa:

Rockefeller Foundation

Fulbright Foundation

Ford Foundation

Smith Mundth Plan

Cooperative for American Relief Everywhere

Multilateral agencies:
World Health Organization

United Nations International Children’s Fund

Other United Nations agencies (e.g., United Nations Educational, Scientific, and
Cultural Organization; Food and Agriculture Organization of the United
Nations; International Labor Organization)

 

58

In 1953, the malaria control section was elevated into a division, under the
Bureau of Disease Control. By 1955, a nationwide malaria control program called
The Six-Year Philippine-American Malaria Control Program was launched. The
objective was to reduce malaria to a level where it no longer constituted an
”important public health problem" and "to develop a long range program of more
permanent measures whereby the Philippine Government, with its own resources, can
keep malaria under control and eventually eradicate it” (Ejercito et al., quoted in
Doria 1964:136). The indirect objectives of the program noted by Doria (1964:138-
139) were consistent with the agenda set forth in the Bell Trade Mission mentioned
earlier:

1. Enable the opening of additional arable land for economic

development thus reducing the imbalance between population growth

and productive resources.

2. Improve the environment for more production of goods and services
and for the investment of capital.

3. Provide a tangible and direct government service to the remote
population groups, thus promoting political solidarity.

4. Promote social justice by freeing the people from the ravages of
malaria.

As is apparent in the above-mentioned objectives, the schema of malaria
control continues to be predicated upon the motive of commercial and economic
development. At the same time, this motive is complemented by such goals as
”political solidarity" and ”social justice.”

This move toward a nationwide malaria control campaign was predicated on

the results of the Malaria Control Pilot Project in Oriental Mindoro conducted in 1953

59

by the Department of Health with financial and technical assistance from ICA and
WHO. The stated purpose of this project was to assist the Philippine government in
ascertaining whether applying a residual spray of DDT to houses was an "effective
and economical method of controlling malaria” (Doria 1964:975).

An administratively centralized Division of Malaria under the direction of Dr.
Antonio Ejercito provided coordination for 30 field units. The Philippine government
provided the technical staff, field personnel, and operational and maintenance
expenses. The U.S. government, through the ICA, contributed technical consultants,
transportation, insecticides, sprayers, laboratory equipment, and other supplies.

A revised plan called the Malaria Eradication Program for the Philippines was
initiated in March 1956. The objectives were revised from control to eradication by
advocating total insecticidal coverage with DDT of all houses in malarious areas for a
period of four consecutive years. Eradication refers to the interruption of
transmission and the elimination of the parasite reservoir by intensive, meticulously
conducted operations that are limited in time. On the other hand, the term "control"
means measures that will reduce transmission to low levels and must be maintained
indefinitely (McGregor 1985:423).

The Philippine campaign represented the first nationwide testing ground for
malaria eradication in the Western Pacific Region (USAID 1961). The concept of
global eradication of malaria was adopted at the Eighth World Health Assembly
(WHO 1973). According to Yekutiel (1981), this move was taken in recognition of
signs of anopheline mosquitoes developing physiological resistance to DDT, rendering

the idea of indefinite residual spraying with DDT impracticable, and the difficulty of

60

sustaining the program because of the limited resources of governments.

In his opening address as conference chairman for the Second Asian Malaria
Conference held under the auspices of WHO in 1974 in Baguio City, Philippines, Dr.
Ejercito, the conference chair, declared:

We are already well aware that we are gathered here not as
representatives of the governments and countries from which we came,
but as representatives of knowledge and experience in malariology. We
are gathered here as experts to discuss technical matters pertaining to
malaria and its control; to exchange problems which we encountered in
the field; how they have been solved, and are being solved... and to
reveal the results of our scientific studies and their practical
applications in the field of malaria control. Placed on a vantage point,
vis-a-vis to you, my friends, I cannot help but visualize that we shall be
building in our midst a "lighthouse" that will illuminate the modus
operandi of malaria control in those regions, that will charter the
rational and right course of action to free our peoples from the ravages
of the dreadful malaria in this part of the globe. Ours, therefore, is a
great responsibility to review what is old, and to point out what is new
in malariology, so that our accomplishments will reflect coordinated
and standardized procedures to combat malaria on intra and inter-
regional levels. This reminds me of our "battle-cry" in our
organization: "Fight Malaria With Knowledge. " [italics added; cited in
Doria 1964:111-112]

Ejercito’s remarks reflect the heavy reliance of the antimalarial campaign on technical
knowledge and strategies of biomedicine and public health. His exhortations also
illuminate the military metaphors used in the campaign.

By the end of 1956, an impressive reduction in malaria had been achieved.
However, the program began to face the problem of expansion from the originally
defined malarious areas. For instance, in the province of Isabela, USAID (1961)
noted that there was an increase of 68% in the number of cases of malaria (from
264,000 in 1948 to 444,000 in 1960). This was a result of the government’s policy

of resettlement from overpopulated nonmalarious regions (along the coast and plains)

61

to less economically developed regions at the edges of the great valleys, which were
also malarious. Parenthetically, my informants in Masipi made reference to this
government program when talking about the period in which people from the
provinces of Ilocos Norte and Ilocos Sur migrated to the Cagayan Valley.

Notwithstanding the added funds given by WHO to strengthen the surveillance
scheme,23 an assessment conducted by Dr. P. Yuketiel of WHO in 1959, concluded
that transmission had resumed on a "considerable scale and in fairly scattered
distribution throughout the discontinuation areas" (Yekutiel 1959, cited in USAID
1961: 12).

The program began to address the mounting obstacles to achieving the goal of
eradication. The program had to contend with the development of mosquito
resistance to a residual insecticide (Dieldrin) in 1959, movement of population,
withdrawal of financial support from the U.S.-funded Mutual Security Agency to
many areas, absence of sufficient funds to finance total spray coverage, and the
decentralization of the Division of Malaria of the Philippine Bureau of Disease
Control that resulted in administrative confusion (USAID 1961). Malaria resurgence
ensued.

By virtue of Republic Act No. 4832 of 1966, the Malaria Eradication Service
(MES) was established under the Department of Health. This act provided for a

centralized management or "vertical control” of the program. As reflected in Figure

 

23WHO financed the hiring of surveillance personnel to carry out visits in all localities
within the consolidation area every three weeks, that is, "areas where spraying operations
have been discontinued and consequently vectors may become sufficiently numerous and long-
lived to reestablish transmission" (McGregor 19852428).

62

10, several specialized units such as entomology and microscopy constituted the
antimalarial program. Residual spraying of houses with DDT assumed greater
prominence in the ”war against malaria.”

External assistance from USAID was extended to June 1973. USAID
assistance included provision of 10 malaria specialists and imported commodities, and
WHO provided four advisors, including a training officer. In addition, 20 U.S. Peace
Corps volunteers were assigned to the program (T iglao 1975).

In 1970, the Philippine government, with the support of WHO and USAID, set
up a strategy review team composed of a representative from the Department of
Health as chair, a WHO consultant and someone from the U.S. Department of
Health, Education and Welfare. They concluded that, given the technical,
administrative, and operational problems confronting the Malaria Eradication Service,
a nationwide, time-limited eradication program was not feasible. According to
USAID (1961:110), the team’s recommendations, which were adopted by the Malaria
Eradication Service, included the following:

1. Where malaria transmission has almost been interrupted and the

endemicity is very low, malaria work may now be systematically

integrated into the general health service. Rural Health Units, acting as

passive case detection posts, should be vigilant of any resurgence of the

disease. Provincial Health Officers, City Health Officers and Regional

Health Directors shall be responsible for any breakdown in the program

at this stage. The provincial health officer should have mobile teams of

sprayers and canvassers and a sufficient reserve supply of DDT and

spraying equipment to conduct, without delay, focal spraying and

epidemiological investigations where a flare up occurs.

2. In other low incidence areas, the gains achieved should be

maintained by an adequate surveillance mechanism involving active and
passive case detection.

63

Philippine Malaria Eradication Service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

W63: ................ {secretary or Health |
Agencies I
I Undersecretary for
I Health a Medical Services
, I
l
: Malaria Eradication c.2123“ DisgasemmCo‘itfttol [Regional Health Directod
t and Medal Service
t Mamba. Dueaor. Bit. of Disease Cudrol
. ' of Heath and Ned. Prqedt
. One! of Field Opel-diam
t One Regional Health Diet-ad
. Oust. Divnionorualana
l
I. --------- 1 - - - - Division of Malaria
. I

 

 

 

[WHO Malaria Advisors] [AIDMalaria Advisors]

[Epidwfiolgsical Services] |Ciericai Stan| [37min lOPrmmfl
I J

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I I I W
Epidemic“ ' logy Entombgy Recording' 108m. ' Amt
t W 2 Mists I t um: . 1 Sanitary Bags-er _
4 MW ‘ ‘ 1 W M I m IRw - . ’1
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Epidemiological Services Spraying OPmfiom Clerical sun
it rm more dun it agree more Iran
600 W 500.000 pnpuldsun
lnvesti tion Unit Parasitological
tucé’w vwmn on.
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Epidemiological Special Investigation Parasimlogy '
Services i W tad-lean W Smmylggm M 8"“
7 m 1m ' 2 W Aldus W m 1;; I
i Spay-n (l or Auxiliary Supervuor Auxiliary
more pa w) Spam Superv'uory Mo 1:4 spam

 

 

 

 

 

 

 

 

 

 

l
Squad Leader
Squatliaarler Ratio 1:3 to6

 

 

 

 

Figure 10. Organizational Structure of the Philipine Malaria Eradication Program
Source: Department of Health. Philippines (1963)

54

3. There are areas referred to in MES reports as ”hard-core areas"
where eradication measures appear not to be making sufficient impact
on the epidemiological situation. In some of these areas, malaria
eradication is at present impracticable. However, because the disease
impairs the health of the people, appropriate control measures have to
be undertaken both for reasons of health itself and for providing the
healthy manpower for the economic development of the areas. [italics
added]

Also in the same year, the government (under martial law) of President
Marcos issued Presidential Decree No. 70 to overcome serious setbacks in malaria
eradication campaigns on account of the refusal of houseowners to cooperate in the
campaign. Below are excerpts that point to, among other things, the rhetoric of
people’s welfare, economic progress, and the exercise of police power by the state
(see Appendix):

Section 1. To insure a successful campaign for the eradication of
malaria in the Philippines in order to promote general health and
welfare of the people as a whole and to alleviate specifically the
injurious effects of malaria on agricultural productivity, rural
development, industrial endeavor and community development, anti-
malaria workers of the Malaria Eradication Service of the Department
of Health are hereby authorized:

a. To enter private premises, dwellings and yards without
being guilty of trespass thereof, in order to spray the
houses or to canvass for malaria cases, take blood films,
give treatment and other anti-malaria activities necessary
to eradicate malaria;

Section 3. Anti-malaria workers shall see to it that the insecticide
residue on sprayed surfaces, being essential to the success of the anti-
malaria program, shall not be willfully removed but must be allowed to
stay on the wall until the termination of the spraying campaign.

Section 4. Any person who refuses or obstructs an anti-malaria worker
from the performance of the duties provided in this Decree or refuses,
without just cause, to allow said worker free entry to his premises
during a malaria control campaign shall be fined not less than three
hundred pesos nor more than five hundred pesos, or by imprisonment

65

for not less than one month but not more than three months, or both,
depending upon the discretion of the court.

This decree clearly represents the state’s strong move to deal with local resistance to
DDT spraying. It requires intrusion into people’s homes (”To enter private premises,
dwellings and yards without being guilty of trespass”).

Since 1973, support from USAID has been withdrawn while that from WHO
has been reduced to laboratory supplies. As a result, the program had to contend
once again with such problems as lack of manpower to implement the program. To
understand this withdrawal of USAID financial support for antimalarial campaigns,
the observations of Voulgaropoulos (n.d.:9) are instructive:

By the late 19603 rapid population growth had replaced malaria as the

major health-related obstacle to development. Robert McNamara of the

World Bank exhorted developing countries to limit their populations or

face the prospect of continued underdevelopment and perhaps no loans.

The US Agency for International Development (USAID) began

supporting family planning programs in 1965 with a budget of about

US $2.1 million. Since that time USAID and some foundations have

allocated millions to universities and institutes to study the problem,

develop techniques and spread the gospel. In 1968 the US Congress

substantially increased funds available to USAID for family planning

and population programs. By 1976 USAID expenditures through the

Office of Population had reached US$154 million yearly--60% for use

in programs in Asia and the Pacific.

Put differently, the shifting funding priorities of international aid agencies condition
the viability of programs such as the antimalarial program.

In 1970, the malaria program strategy was changed from eradication to
control. This move was in consonance with the shift of the global antimalarial

strategy espoused by WHO. In 1969, WHO conducted a reexamination of the global

malaria strategy and arrived at the following conclusions, which later became the

66

basis for the revised strategy of malaria control (Yuketiel 1981:470):

1. The planning and budgeting of malaria eradication programmes
were not included in or coordinated with the overall national economic
development planning. Consequently many eradication programmes
had been handicapped by lack of sustained government support.

2. Many countries had embarked on eradication programmes without
realizing the extent of commitment involved.

3. Technical factors including exophilic habits (outside biting and
sheltering) of vectors, insecticide resistance, and factors of human
ecology (e.g., seasonal migration, habit of sleeping outdoors) though
affecting about 1% of the areas with eradication programmes, had

an adverse operational and psychological impact quite out of proportion
to their size.

4. Serious operational deficiencies were almost invariably encounter-
ed. The present methods of eradication, although simpler than those
available before... are still laborious and often too expensive for the
limited resources of developing countries; unless the present
methodology is further simplified, global eradication, though
theoretically possible, will continue to be beyond reach for many years
to come. [italics in the original]

The continued influence of WHO directives over the nature of the organization
and operations of the Philippine Department of Health was expressed in the
integration of the Malaria Eradication Service into the general health services as
stipulated in Executive Order No. 851 dated December 2, 1982. This change pursued
the so-called Primary Health Care (PHC) approach endorsed by WHO in 1978.

Thus, the Malaria Eradication Service was again decentralized. Dr. Azurin, then
Minister of Health, however, provided the following justification:

In essence, the integration streamlined the operations of the MOH

[Ministry of Health] by establishing a unified and continuous line of

authority and responsibility from the central level to the district levels.

The artificial line that separated public health from medical (hospital)

practice was removed, resulting in a more comprehensive delivery
network at the local level. [Azurin 1988:43]

67

The Department of Health went through another reorganization in 1986 under
the Aquino government. To solve the administrative problems faced by the
antimalarial program, a semivertical organizational structure for the antimalarial
program was formalized by Executive Order No. 119. Also, the program was
renamed the Malaria Control Service and became a staff bureau under the Office for
Public Health Services (see Figure 11). My point here is that, notwithstanding the
changes in the approach to the management of the malaria program (i.e., vertical,
integrated, and semivertical approaches), the program’s top-down decision-making
process remains in place.

In 1990, a renewed optimism occurred in regard to the control of malaria in
the Philippines. This was due to the inclusion of malaria control as a key component
of the Philippine Health Development Program, with a loan provided by the World
Bank. The goal is to attain an annual parasite index of 1/1000 population by the year
2000. This goal is reminiscent of the optimism of the 1950s when the program was
heavily supported by USAID. External aid, thus, plays a prominent role in the
waxing and waning of optimism surrounding the antimalarial activities in the country.

On July 1992, Dr. Juan Flavier, the Secretary for the Department of Health,
issued Memorandum Circular No. 1 series 1992, phasing out DDT spraying as a
control measure. Ironically, the same memorandum provided for the substitution of
other insecticides for DDT, namely Solfac, K-Othrine, Icon and Permethrine. The
document claims that these insecticides do not have adverse effects on the
environment and health. This point, however, was challenged by a recent external

review, which noted that the insecticides now being used in place of DDT are not

68

Philippine Malaria Control Program

 

LSecretary or Health ]

 

 

 

 

 

 

 

 

Office for 0min for
Public Health ‘ """"" ‘ " " Management
Services Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IMalariaControl -

Plansand Programs
Division

 

 

----J

 

 

 

Epidemiology I
and Reaemch

Division

 

 

 

 

 

Executive Committee for
National Field Operations

 

 

 

 

,. - .. - JJRegional Health Office]
I
l Malaria Regional
“I “ Coordinator &

, Staff

' ------ l Provincial Health 0am

.. Provincial

 

 

 

 

 

 

----‘

 

 

 

 

[Bisuict Health orrroe I

 

 

D' .
Malaria
Coordinator

[ Rural Health Unit 1

 

 

 

 

 

---r ‘4 ‘J

 

 

LBarangay Health Station]

 

thure11.0rganizational StnrctureoftheMalariaControl Program
Source: Malaria Control Service (1987)

69

only more expensive but also more toxic than DDT (Palmer et al., 1993). Despite
these contradictions, the antimalarial schema remains anchored in the primacy given
to mosquito control through house spraying with insecticides.
Conclug'gg Remarks

The antimalarial schema in the Philippines has had several salient features
from the turn of the century to the present. First, the antimalarial schema, from its
inception to the present, has rested on biomedicine and epidemiology, both of which
shaped the development of antimalarial strategies that largely revolved around the
mosquito-plasmodia aspect of the disease. These strategies include mosquito vector
control, using chemicals and insecticides, and chemoprophylaxis, using antimalarial
drugs. This orientation remains well-entrenched, despite shifts in the antimalarial
program’s philosophy (i.e., from control to eradication, then back to control).

Secondly, the antimalarial schema, from its inception to the present, is
structured for a health care bureaucracy that promotes hierarchical social relations
expressed in a centralized decision-making process. Whatever operational strategy the
health bureaucracy has adopted (i.e., vertical, integrated, or semivertical), the schema
has remained oriented towards top-down policy making and implementation. By
extension, the schema promotes professional dominance in the definition and
management of health problems such as malaria.

Thirdly, it could be suggested that the antimalarial schema, since its
emergence, has depended heavily on external financial and technical assistance. Its
resources and capabilities always remain subject to the shifting priorities of

international donors. External support, thus, promotes not only the above-mentioned

70

features of the antimalarial schema but also the patron-client relationships that the
Philippine state has forged with the U.S. and international health and development
agencies.

Finally, for its continued justification, the antimalarial schema employs the
idioms of nation-building, economic progress, political solidarity, and social justice.
These idioms are reinforced by the use of Western approaches to health, medicine,
and development. How these key attributes of the antimalarial schema clash with the
ways in which the Ilokanos struggle against malaria will be elucidated in Chapter

Five.

Chapter Four

MALARYA IN OUR MIDST

This chapter deals with the ways in which the Ilokanos of Masipi construe and
deal with m, viewed within the context of their ethnomedical knowledge and
practices. I find it appropriate to use the term Marya, the local term, to direct
attention to the ways in which the Ilokanos experience and discern malaria. The
concept of m is continually reshaped by local cultural experience in social
interactions in homes, hospitals and clinics, pharmacies, and other settings.

The first part of the chapter discusses the local understandings and
management of the body in relation to health and sickness. I present a case study of a
woman who died of cerebral malaria to illustrate the point that the local ethnomedical
system is grounded in a cultural logic that maintains the interconnections among the
physical, social, and moral spheres of human experience. As will be demonstrated in
the second part of this chapter, this cultural logic guides the local constructions of the

etiology, prevention, and treatment of malma.

71

72
I] Ehnm'lanle anPrcti

Two related terms, sake; (sickness) and saw—nit (health), frequently arise in
my conversations with the villagers about the state of their pammagi (bodily
condition). I note, however, that in most of my talk with them it is the notion of
saw that assumes greater prominence, especially when they are asked to characterize
their own pammagi. This, according to them, is because they are alerted mostly to
the condition of their pammagi when it is invaded by a 1am. I take this as
suggesting that M is intrinsic to the pammggi; that is, the pammagi per se
presupposes a healthy state or absence of Lake; So, in the local view, to ask
questions about the pammagi amounts to calling attention to the experience of SM
and how it figures in one’s pammagi.

The oft-mentioned markers mg) of sak_et_ include a pale skin, reddish or
yellowish eyes, vomiting, fever, loose bowel movements, restlessness, lack of
appetite, moaning, crying, quarrelsomeness, sleeplessness, chills, headaches, spitting
blood, and an inability to carry out one’s daily routines and meet one’s obligations.
These bodily states and personal conduct as signs of sickness are talked about in
relation to the notion of naturalesa, which refers to the body’s "in-born" vitality and
capacity to withstand any stressful situation. Also, people talk about mm along
with the person’s km (syn., ugafl) or conduct. Here, the idea of managing one’s
thoughts (2311mm!) and feelings (rik_n_a) comes into play. One’s Ems; emerges from
the manner in which a person relates to members of his immediate family

(sangabalayan), kin (kLbagyfl), and neighbors (karruba). Kinagg is also talked about

in terms of a person’s relationship with deceased relatives, especially those with

73

whom a person has spent considerable time. For instance, when referring to a
particular individual, people often use the idioms of W (”bad
conduct") and W ("good conduct”).

The local discourse on SM stresses the interaction between naggralesa and
M. For instance, sake; is frequently construed in terms of the idea of m
wenno migsa nga naturelasa (”weak or strong namralesa"), especially when talking
about a chronic sickness. At the same time, a person’s namralesa can either be

enhanced or undermined by one’s kinatao-—”Makapapigsa iti naturalesa iti nasayaat

 

nga kinatao" ("Good conduct strengthens one’s natural vitality").
The Fate of Ligaya

At this point, I present a case of how the local ethnomedical system shapes the
management of mam. The case illustrates, through the actions of family members
and neighbors, the embeddedness of m_alma in the social world of the Ilokanos. The
case is about iti ggat ni Ligaya (”the fate of Ligaya"). A resident of Magallones and
a woman in her early 20$, Ligaya died at the district hospital of cerebral malaria.
The ubiquity of m, in that every household has at least one case of the illness,
and the necessity that people feel to take action resonate with diagnostic and
therapeutic strategies employed to address Ligaya’s affliction.

For a number of days, Ligaya had complained about a severe headache, a back
that felt as though it was being scared, and intermittent chills and fever. She thought
that it was a simple case of mm (syn., W, which literally means

"shivering. To deal with this symptom, she took some analgesics and antimalarial

pills that she bought from a nearby sari-sari store. The medications did not relieve

74

her sickness.

One day she passed out suddently, and she was rushed to the district hospital.
There she demanded to be brought to the payward24 and although her father-in-law
was hesitant, he was obliged to carry out her wishes, out of embarrassment. After
two days, she was brought home because her in-laws claimed that the hospital staff
were unfriendly and unaccommodating. Her father-in-law claimed that she had shown
no improvement, which led them to think that she needed a local healer.

Some neighbors advised Ligaya’s husband and her in—laws to continue
allopathic medical treatment while seeking the help of local healers. The father-in-
law, however, insisted that he did not have enough money for hospitalization, no
matter how they prodded him.

The family then sought the help of Delya, a local healer from a nearby
mama. She examined Ligaya’s body and found that the line from her navel down
to her pubis was dark and crooked. To Delya that was a sign indicating Ligaya’s
inherent vulnerability to misfortune. This vulnerability could also affect her close
relatives.

Delya led a name-changing ritual, saw—iti, to change Ligaya’s name and hence
to change her gasgt (”fate”). The m was performed in a nearby river. Delya
washed Ligaya’s hair with soap while an elderly man, who was to become Ligaya’s
”godfather,” was striking a piece of bamboo with a m (a large heavy single edge

knife) rhythmically. The name ”Alicia," Ligaya’s new name, was uttered in unison

 

2‘The payward is a section in the hospital for patients who can afford to pay for
private or semi-private rooms and hospital services. The charity ward is for indigent patients.
Thus, these two sections in the hospital are markers of social status.

75

by the participants, who included her husband, her parents and parents-in-law, and
neighbors. Ligaya, however, was not cooperative. She swore at everybody and said
that the ritual was the work of the devil. Among the participants, however, her new
name was expected to give her a new life, freeing both her and her relatives from bad
luck.

Delya also performed a divination ritual called made. She dropped nine rice
grains into a plate with water, chanted, and then said that the arrangement of the
grains indicated that Ligaya encountered some ”unseen beings” (saan nga mgitkita)
when she washed clothes by the river. Delya said that Ligaya accidentally hurt a
spirit in the river, which retaliated by causing her persistent sickness. A m, an
offering consisting of three pieces of tobacco, three candles, a box of matches, some
betel nuts and betel leaves, lime, and a bottle of gin, was placed at the foot of a tree
near the river, to appease the spirit that had caused Ligaya’s affliction. Delya also
asserted that Ligaya’s regular washing in the river exposed her body to hot (Mt)
and cold (la_mii_s) elements, which weakened her naturalesa.

Ligaya became very quarrelsome, lost her appetite, hardly slept, and grew
hysterical. To many, Ligaya was exhibiting signs of W (loss of sanity), a
result of W (spirit possession). Not only was Ligaya’s speech unintelligible
but also her conduct was uncontrollable and violent. Her neighbors were getting
more and more concerned. Discussions about her difficulties (11mm, such as her
strained relationship with her father-in-law, began to surface. Ligaya was greatly
upset by the loss of their cow. It was rumored that her father-in-law sold the cow to

pay for a long-standing debt to a local landlord (hasyingerg). Then, Ligaya’s pig was

76
hacked to death because it went astray. These frustrations, her neighbors believed,

were aggravated by the shocking sound of truck tires that burst on their way back to
the village from the hospital.

The government-paid midwife, against considerable resistance, took a blood
smear from Ligaya and submitted it to the Rural Health Unit in the town proper. It
tested negative for malaria. However, the midwife expressed her concern over
Ligaya’s erratic behavior to the physician at the municipal health office. Perhaps
thinking that this was an opportune time to campaign for his nephew, who was
running for a municipal office, the physician agreed to see Ligaya personally. After
seeing Ligaya, the physician visited some local leaders to ask their support for his
nephew. According to the midwife, Ligaya was injected with an "antipsychotic"
drug, which not only calmed her but also helped her eat and sleep. Ligaya’s
husband, however, did not pursue further treatment of this kind and said that his wife
was already too weak to bear more injections.

Manolito, another local healer, was summoned by Ligaya’s father-in—law.
Manolito advised Ligaya’s husband and parents-in-Iaw to pray for their dead because
they were making their presence felt through the sickness of Ligaya. He said that the
dead were asking for their share in the fruits of the labor of their living relatives.
They had to perform a W ("remembering"), involving prayer for nine days
(a novena). Manolito said that Jesus and the Virgin Mary were displeased because
Ligaya destroyed their images when she converted from Roman Catholicism to the
Baptist Church. The family was advised to replace the images so Ligaya would get

well. The family did, but Ligaya’s health continued to deteriorate.

77

Concerned neighbors and some harangay officials prodded Ligaya’s family to
take her back to the hospital. The father-in-law, however, was adamant in saying that
they had no money to spend. He believed that the local healers could deal effectively
with Ligaya’s affliction. He summoned Delya once again. Delya asked for a bible.
Perhaps expressing his cynicism, Ligaya’s husband threw the bible toward the healer.
Then Delya asked for a white chicken, which the family was unable to provide. She
then asked for a glass of lukewarm water in which she dipped her metal pin,
signifying her membership in the Cruzado, a religious sect that draws on Roman
Catholicism. The pin was believed to have healing power. She asked Ligaya to
drink the water, which was supposed to have been blessed through her prayers and
her act of dipping the pin. Ligaya, however, didn’t want to drink the water, refused
to face Delya, and called her names such as demgnyg (devil).

All these treatments took place within a period of 14 days. On the 15th day,
the ambulance from the Rural Health Unit (RHU) came to pick up Ligaya. The
message about Ligaya’s condition had been relayed through the radio facilities in the
military detachment in Magallones to the Rural Health Unit in Cabagan. My research
assistant and I rushed to Ligaya’s residence. There I saw her lying motionless in the
old lounging chair in the middle of the house. Her body was racked by intermittent
convulsions while her bony hands, also seized by spasms, were stiffly stretched
alongside her rigid body. Her sunken eyes stared blankly at the empty ceiling. The
heavy heaving of her emaciated chest was acwmpanied by a hissing sound as she
painfully expelled air from her lungs. She was brought to the ambulance in a

stretcher around noon. Around 2 am. the next morning, Ligaya’s uncle announced

78

her death and summoned the husband of my research assistant to help transport
Ligaya’s body from the district hospital. I learned that they had to carry Ligaya’s
body in a hammock because no commercial vehicle would accommodate such an
emergency. To do so would mean inviting misfortune on the vehicle owner. Twenty
male Magallones and Compra residents, most of them Ligaya’s relatives, took turns
carrying the corpse for 15 kilometers. Ligaya’s body arrived in the village at the
break of dawn. Her father-in-law reported the doctor’s diagnosis: Ligaya had died of
cerebral malaria, complicated by pneumonia.

A striking feature of the three-day wake was the public display of grief in the
W (dirge). The W was invariably expressed in terms of the idiom of
kakaasi iti gasat mg ("your unfortunate fate”). With deep emotion, relatives and
friends spoke to Ligaya’s corpse. They praised her for being jolly, industrious, and
forgiving, but they also blamed her for not taking good care of her body, for allowing
her saket to overpower her naturalesa, and for leaving her three young children
behind.

In the cemetery, a minister of the Cruzado sect prayed over the corpse before
it was buried. The people then went back to Ligaya’s house for the final burial rite,
the buggg ("to wash"). All those who had gone to the cemetery had to have their
faces and necks washed by three widows to prevent perpetual bodily disturbance such
as dizziness and aches.

Ligaya’s Lam (soul) was believed to hover around the places familiar to
her before she died and could not go to heaven until the ninth day of her death, when

her soul would realize that it no longer had a body to return to. A number of

79

relatives and neighbors joined the bereaved family in prayers on nine consecutive
nights. This process also entailed the offering of 5am, which consisted of locally
prepared food and pastries, a Roman Catholic bible, and candlesticks laid on the spot
where Ligaya’s corpse had lain. To facilitate the communion of Ligaya with other
dead relatives, a group of women invoked their names and asked all of them to
partake of the food.

Ligaya’s story shows how the Ilokanos draw on their ethnomedical system to
address an affliction such as mail—arya. As with any affliction, the Ilokanos interpreted
Ligaya’s suffering as originating from personal conduct and bodily attributes. It also
shows how the "quest for therapy" and management of suffering involved the
mobilization of social networks (cf. Janzen 1978).

Experiencing Malaua

This section further explores ME in relation to the local ethnomedical
system. It is based on my survey work and extended interviews with community
members. I have identified cultural themes emerging from these interviews and from
the responses to the open-ended questions in the survey. These themes illuminate the
villagers’ cultural understandings of mm.

M is a borrowed word that has acquired characteristic meanings in
consonance with the local cultural understandings of health, sickness, and healing.
One key marker of mama is the experience of chills or shivering (agpayggpeg).
MM and W are often viewed as equivalent. For instance, a person
experiencing the sickness would talk about his or her state as AW ("1 am

suffering from malaga") or W ("I am suffering from chills”). When

80

asked if there are different types of m, 32% (n= 100) suggested two types,
which distinguish not only how the body behaves or what the body feels when
afflicted with mam but also severity and threat to life.

The first type is malma natural (syn., malaga regular; malma latta,
meaning, "simply M"). It is marked by incessant shivering, recurrent fever,
and headache. Informants have this to say:

”You shiver uncontrollably, feel cold, then suddenly your temperature
rises.”

”It is just regular malarya, you just shiver uncontrollably, with fever
and a headache as if your head will split."

Informants call the other type of m as malma maligna (probably
derived from ”malignant malaria," which healthworkers use to characterize cerebral
malaria). This type is marked by little or no shivering, one of the key bodily markers
of malma natural. Informants put it this way:

"It begins with ‘hair standing on ends’ (chills), followed by fever, then
headache."

"It is mm with no chills, just fever and headache.”
"You don’t sweat, and you have yellowish eyes."
"It is not like W, it is trapped inside your body.”

"It is the more dangerous kind, it can lead to mental derangement, even
death.”

”It is deceptive (traydor) because, if ignored, it goes to your brain
(mapan ta utekmg), leading to mental derangement namau on , or
even death."

81

Most respondents consider malaria, especially malarya maligna, a dreaded
sickness (85%, n= 100). Table 10 indicates the various reasons people give for
dreading m, foremost of which is that it can be fatal (72.9%). Some
respondents, on the other hand, report that they do not dread Marya (15%, n= 100).
Table 11 presents the respondents’ reasons for not dreading m_ala_rya, the most striking

of which is that it is a sickness that happens "naturally" and that it can be ”cured."

Table 10. Reasons that mlafla is dreaded

 

no. %
It’s fatal 62 72.9
It’s fatal and leads to mental derangement 19 22.3
It’s fatal especially when you’re short of money to
buy medicines or to pay for hospitalization 5 5.8
It affects your work especially when everybody
gets sick 3 3.5

 

n=85 respondents; percentages total more than 100 because of multiple
responses per respondent.

Table 11. Reasons that malarya is not dreaded

 

no. %
We attend to the sick person immediately 10 66.6
It comes naturally as a sickness 3 20.0
It’s curable 3 20.0
I’m the only one who gets it in the family 1 6.6

 

n= 15 respondents; percentages total to more than 100 because
of multiple responses per respondent.

82

Table 12 indicates the distribution of mm across the sample households
and shows that the majority of the sample households (89%, n= 100) have had at least

one case of mama in the last year.

Table 12. Cases of mala_rya reported in each household in the last year

 

no. %

Households with a least 1 case of malgya in the last year 89 89

No. of
No. of cases households (n=89) %
1 34 38
2 35 39
3 15 18
4 3 3
5 1 1
9 1 l
Households with no cases 11 11

Total 100 100

 

83

The Ilokanos attribute the causes of mama to several factors. Malma is
due to the undermining of a person’s naturalesa through overwork, lack of sleep,
frequent bathing in the river, or exposure to cold weather. Also, these practices upset

the balance of pudot (heat) and lamiis (cold) in the bag; (body) which can lead to

 

mm. Drinking water from a spring or open well also causes m_alma because this
water is full of Lugjt (dirt) or iita (venom) found in itlgg ti lamuk (mosquito eggs).
Respondents gave a range of responses to the question asking what caused the
case(s) of magma in their households, as shown in Table 13. The local cultural logic
that underlies m_alaga causation has two complementary aspects. The first is that a
person’s everyday routine in relation to environmental conditions affects the
functioning of the bagj. In this regard, strenuous activities (whether work, leisure, or
even sexual activities) "burden" the body, predisposing it to sickness. The cause of
mm is, thus, partly explained in terms of the sudden exposure of the "strained”
hagi to hot or cold elements. In short, mm is believed to be caused by a
disturbance of the balance between hot and cold in the body. This logic falls under a
broader local term, m, meaning, "affliction due to sudden exposure,” which

parallels that of humoral pathology.25

 

25Hart (1969) and Jocano (1973) are in agreement that humoral pathology concepts in
the Philippines were carried from Latin America (or directly from Spain) after most of the
archipelago was conquered by the Spaniards in the sixteenth century.

84

Table 13. Causes of specific cases of mama in the household

 

no. %

Tired and got rained on 23 25.8
Overworked 15 16.8
Lack of sleep 11 12.3
Exposure to cold weather 10 11.2
Drank water from spring 9 10.1
Bathed after heavy work 9 10.1
Bathed frequently in the river 8 8.9
Bathed habitually in the

afternoon 8 8.9
Bathed after playing too much 3 3.3
Bathed after drinking alcohol 2 2.2
Bathed at the onset of a cold 1 1.1

 

n=89 respondents; percentages total to more than 100
because of multiple responses per respondent.

85

Table 14 shows responses to the question why villagers get easily afflicted

with malma, indicating the close link between malma causation and the routines of
everyday life.

Table 14. Reasons that villagers are vulnerable to malarya

 

no. %
Soaked in the rain after heavy work 16 18.1
Overworked 12 13.6

Bathing or washing after heavy work 10 11.3
Weak naturalesa (predisposition to

sickness) 9 10.2
Frequent bathing and washing
in the river 8 9.0

Drinking water from springs and

uncovered dug-wells 8 9.0
Lack of sleep 7 7.9
Exposure to the cold temperature

in the mountains 7 7.9
Bathing after too much playing 4 4.5
Bathing after drinking alcohol 4 4.5
Staying up late in the cold nights 4 4.5
Getting bitten by mosquitoes in the

mountains 4 4.5
Bathing even without enough sleep 3 3.4

 

n=88 respondents; percentages total to more than 100
because of multiple responses per respondent.

86

Consistently, informants tell me that they cannot escape mam, that all
residents are predisposed to malaria. Farm work is heavy work, people say. Heavy
farm work coincides with the onset of the rainy season, hence, they cannot avoid
getting soaked. Harvest season is demanding, so getting overworked is the order of
the day. Some men are engaged in logging or firewood gathering; hence, they are
exposed to lamok ti bantay ("mosquitoes in the mountain") whose bites are
”venomous.” There, they drink spring water, making themselves vulnerable to
m_almz_1. Women wash clothes, utensils, and other household items in the river, then
they take a bath, so their bodies absorb too much mis (”cold”). Also, children
habitually swim and play in the river while they tend their carabaos (water buffalos).
Still, some informants maintain that there are those who are born with weak
naturalesa and, hence, are simply predisposed to m, including mam.
Additionally, they contend that bathing a weak body (e. g., due to not having enough
sleep) simply leads to M, especially m_ala_r3La.

Another aspect of the local logic is that m_alarya is caused by the intrusion of
substances, such as ru_gi1 (dirt), dig (venom), and mikrgbio (germs), into the hagi.
These two properties of the local logic, moreover, implicate the body’s naturalesa,
with which individuals are differently endowed. Natuglesa, thus, as part of the local
logic about sickness causation, renders intelligible the dynamics of human activities or
”bodies in action" with environmental elements such as angi_n (air) and datum
(water).

Table 15 indicates the explanations given by respondents who claim non-

affliction of W in their household for the past year. Noteworthy, however, is

87

the invocation of the role of merciful Am Digs (”God"), routinely acknowledged for
any blessing--good health, bountiful harvest, peace, and so forth--a person, a family,
or the whole community experiences. The rest of the explanations follow the local

logic about malarya causation previously described.

Table 15. Reasons that nobody in the household has had malaga

 

no. %

With the mercy of A129 Digs 5 45.4
Use of mosquito nets 3 27.2
Maybe we have strong

naturalesa 3 27.2
Husband seldom goes to the

mountains 2 18.1
Perhaps no ”mama-giving"

mosquito has bitten us 2 18.1
We observe cleanliness 1 9.0

 

n=11 respondents; percentages total to more than
100 because of multiple responses per respondent.

Local understandings about the spread of magma by mosquitoes is based on
the logic that mosquito bites contain sickness-causing ”poisonous substances" such as
rugi_t (”dirt”), mikrgbyg ("germs"), and dia ("venom”). Mosquitoes ingest these
substances for they thrive in toilets, garbage pits, and other nabangsit nga lugar
("odorous places”). Mosquito bites transmit these substances. It should be noted,
however, that the spread of mama is attributed not only to mosquitoes but also to
other insects such as flies and cockroaches. Like the mosquitoes, these insects also

spread rugit, mikrgbyg, and dig. In addition, villagers classify mosquitoes into two

88
types, namely, bassit nga lamuk (small mosquitoes) and lamuk ti nuang (carabao
mosquitoes). Also, they assert that it is the lmuk ti nuang that spread mama while
the bassit nga la_n_1uk are considered as a mere nuisance especially at bedtime.
Table 16 shows the explanations given as to how mm is transmitted. The
responses point to a logic of pollution and contagion brought about by the intrusion

into the bagi of the contaminating elements mentioned earlier.

Table 16. How malma is transmitted

 

no. %
Bitten by a mosquito that came from a
person with malma 17 48.5
Inhaled the sick person’s ”hot” breath 8 22.8
Ate a sick person’s leftover food 8 22.8
Shared a glass, plate, or spoon with a
sick person 5 14.2

 

n=35 respondents; percentages total to more than 100
because of multiple responses per respondent.

I have indicated previously that from the villagers’ point of view malarya has
assumed a character of ”naturalness" in that residents contend that they are all
predisposed to the sickness and continue to live with it. As one informant put it:
"When you get sick, you just get sick. When it comes, it just comes." It is perhaps
due to this prevailing predisposition that most respondents dismiss the idea that

tum can be avoided or prevented (83%, n= 100).

89

Table 17 presents the various preventive strategies that were given by the
remaining 17% (n=100). The perceived measures follow the logic of countering
forces or avoiding activities that lead to m.

The ”naturalness" of tria_lagta (i.e., it is an inescapable sickness) relates to
the villagers’ sense of time. The pervasiveness of mm in their locale is apparent
in the concept of gempo ti malma ("time of Mm”). This time coincides with
tyempo ti tudo ken lamiis, ("time of rain and cold”). Respondents said that it is
during this time of rain and cold that m is rampant (77%, n= 100; see Table

18).

Table 17. Measures to prevent malma

 

no. %

Taking care of one’s self by using mosquito net 6 35.2
Not using sick person’s belongings 3 17.6
Not abusing your body by working

so early, exposing yourself to the sun,

and taking a bath afterwards 3 17.6
Not going near a sick person 3 17.6
Keeping surroundings clean 2 11.7

Total 17 99.7

 

n=17 respondents

90
Table 18. Characteristics of tyempg ti malgya

 

no. %

Cold season 21 27.2
Changeable hot and cold weather:

it’s rainy, it’s chilly then

the sun shines, the body

cannot cope; it’s sunny then it

rains; cool in the morning and

hot in the afternoon. 17 22.0
Cold and rainy 15 19.4
Get rained on in the farm 8 10.3
Cold weather, mosquitoes

are plenty 6 7.7
Rainy months that induce the

increase in the mosquito

population 4 5.1
Lots of stagnant water in the

surroundings 2 2.5
Rainy days and season of corn

(planting or harvesting) l 1.2
Time when mosquitoes lay eggs 1.2
Mosquitoes thrive on dirty

surroundings, then bite you at

night 1 1.2
Season when people come from

the mountains I 1.2

Total 77 100.2

 

n=77 respondents

91

The Ilokanos employ various strategies to ameliorate mm (see Abaya
1987:63-80). Self-medication is a common practice, which includes the use of over-
the—counter medicines, available at the local sari-sat: stores and pharmacies in the
towns of Cabagan and Tumauini. People also use e_r_ba (medicinal plants) for self-
medication. Often, the villagers use both the services of local healers (mangagas) and
medical doctors to ameliorate mam because the bodily and behavioral
manifestations of matalya overlap with sicknesses caused by unseen beings. This
brings to mind the case of Ligaya, whose sickness involved multiple therapies. The
interpenetrating treatment strategies employed by the Ilokanos in Masipi reflect a deep
sense of pragmatism, involving the creative use of available therapeutic options.

Thus, the introduction of biomedicine did not displace the local ethnomedical system
but rather increased the therapeutic options available to the villagers (Abaya 1987:88).

Table 19 shows the responses given to the question asking what treatment

actions were undertaken to alleviate mama. Respondents view these strategies as

not mutually exclusive but rather as complementing each other.

Table 19. Therapies for malaga

 

no. %

Self-medication
Over-the-counter drugs 83 83
Herbal medicines 32 32
Service of traditional healers 43 43
Service of physicians 80 80

 

n= 100 respondents; percentages total to more
than 100 because of multiple responses per respondent.

92
Shown in Tables 20 and 21 are the various materia madica that respondents

mentioned when asked what medicines do they use to treat malma. The people
combine available plant medicines with biomedical drugs, some of which are

prescription drugs commonly sold over the counter.

Table 20. Biomedical drugs

 

no. %
Antimalarial:
Aralin (Aralen) 42 50.6
Mitakilfin (Metakelfin) 31 37.3
Fansidar (Fansidar) 17 20.4
Klurukwin (Chloroquine) 11 13.2
Halupantrin (Halofantrin) 4 4.8
Atabrin (Atabrin) 1 1.2
Anti-inflammatory:
Alaksan (Alaxan) 10 12.0
Antipfletic/Analgesic:
Bayugisik (Biogesic) 12 14.4
Parasitamol (Paracetamol) 7 8.4
Midikol (Medicol) 5 6.0
Kurtal (Cortal) 1 1.2
Aspilits (Aspilets) 1 1.2
Antibiotic:
Eritromaysin (Erythromycin) 1 1.2
Amusisilin (Amoxicillyn) 1 1.2
Ambrasin (Ambracin) 1 1.2
Dangestant:
Niyosip (Neozep) 5 6.0

 

n= 83 respondents; percentages total to more than 100
because of multiple responses per respondent.

Table 21. Plant medicines

93

 

Dangla (Vitex lagangi L.)
Andarayen (Alstonia scholgia L.)
Kabatiti (Cucurbita maxima L.)
Salamagi (Tamarindus indig L.)
Dalipaweng (Alstonia scholatia L.)
Kaymito (Chrysophyllum cainito L.)
Pengga (Anisomeles indi___ca L.)
Subusub (Blumea balsamiferia L.)
Tarong (Solanum melongena L.)
Taltalikug (Phyllantus ninuri L.)
Mangga (Mangifera indiga L.)
Yukaliptus (Eagalyptus robusta Sm.)
Abokado W Mill.)

 

n=32 respondents; percentages total to more than 100
because of multiple responses per respondent.

94

Villagers seek assistance from local healers, especially for a sickness that
lingers despite attempts to ameliorate it through home remedies and commercial drugs
and medical attention from private and government health professionals in municipal
and provincial centers. A lingering sickness is a sign of sickness caused by "unseen”
beings (e. g., environmental spirits, spirits of dead relatives) or by mud (witchcraft).
The bodily disturbances associated with malarya are recurrent and therefore signal the
need to seek the help of local mgagaa There are at least five was in Masipi.

The mangagas routinely employ divination called talado and massage, using

 

pgl_i, a decoction of different herbs mixed with ”blessed” coconut oil. According to
the three healers I interviewed, they procure their po_li from healers in the town
proper. The healers in the town proper get their supply of M from traditional
healers in San Fabian, a town in Pangasinan province in central Luzon. San Fabian
is well-known for its traditional healers (including those who employ "psychic
surgery").

Iatflq is a process of divination that involves the ”interpretation" of the
configuration of the rice grains spread on a dish covered with water, the position of
an egg dipped in a glass of water, the configuration of candle drippings on fingernails
and toenails, and dreams. Given the lingering nature of mm, seeking the help of
the maagagas is a practical strategy. Invariably, all 40 out of 43 respondents who
sought help from maagagaa for malaria said that they underwent two, based on
being told that their ill health was due to their encounter with m (spirits) while at
work and at play. The other three respondents were told that the sickness signalled

the need to remember dead relatives. To appease these spirits, healers advise the

95

family of the sick person to make an offering (Earl) to these spirits. The Lari is
composed of cooked glutinous rice, dishes, betel nuts, betel leaves, candles, cigarettes
or tobacco, and alcohol. The m is left in a spot where the encounter took place or
on an altar inside the sick person’s house.

Residents frequently express their appreciation for the kaasi ken anus
(”compassion”) of the mangagas, who do not expect ”payment” for their help, instead
they receive m (”gifts") such as rice, corn, and money, which, according to the
healers, is used to purchase pgl_i, candles, and other items used in the healing process.

Concluding Remarks

In arguing for the notion that malgya is rooted in culturally constructed
practices with respect to health, sickness, and healing, I wanted to call attention to the
limitations of the physical reductionism associated with the biomedical paradigm. As
demonstrated in this chapter, the Ilokanos construe and act upon Maria in terms of
their own ethnomedical schema. This schema grounds M in local
understandings about the workings of the body in relation to heat and cold pathology,
the notion of naturalesa (”inherent vitality of the body"), an individual’s kjaatag
("conduct”), and the moral obligations of the living to the spirit world. At the same
time, this schema is a dynamic one in that villagers appropriate biomedical ideas and

practices, resulting in the widening of treatment options available to them.

Chapter Five

ENCOUNTERS OF CULTURAL SCHEMAS

This chapter characterizes the encounters of cultural schemas orienting the
struggles against malaria in Masipi. These encounters are manifested in the
interactions between the local people and the implementors of the antimalarial
program. The purpose of this chapter is to show the workings of domination,
conformity, and resistance in the confrontations between two modes of understanding
malaria and its control--that of the Ilokanos of Masipi and that of the state health
functionaries involved in the antimalarial program.

The first part of the chapter provides a description and interpretation of an
encounter involving the implementation of a new antimalarial strategy, referred to as
”bed-net impregnation with insecticides. " Several steps in the antimalarial program
such as the spraying of houses with pesticides, finding cases and treating them, and
community participation are mentioned in this encounter. The encounter is crucial to
understanding the dynamics of cultural politics of malaria control because it represents
a face-to-face confrontation between the Ilokanos and the program implementators--
that is, a "public transcript" (after Scott 1990), an open interaction between
subordinates and those who dominate. Attention is, thus, given to negotiations over

definitions of reality actualized in the dissemination of official understandings of

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malaria control (e. g., "mosquito as culprit," "malaria and economic progress,"
”malaria as a dreadful disease," ”K-Othrine is safe") and their reception in a specific
public assembly organized by the 12mm officials in compliance with an order from
the Provincial Health Office’s Malaria Unit. The discussion shows the ways in which
power differentials among the participants, the knowledge forms being disseminated,
and the setting of the interactions condition the interplay of domination, submission,
and resistance.

The second part of the chapter explores the ”offstage" discourses and practices
of the Ilokanos that confirm, contradict, or inflect what appears in direct encounters
with the program implementors. Muted in face-to-face encounters with the powerful,
these discourses and practices indicate, to a large extent, local ambivalence and
resistance towards the antimalarial program.

Antimalag’al Progt'am-Cammunity Dames

The observation that the antimalarial program has penetrated the consciousness
of the Ilokanos cannot be overemphasized. The Ilokanos in Masipi are quick to
identify malaria control as a longstanding government service in their area. They
refer to it as malarya kgntrgl, and its workers as tagamalaga kontrgl (”from the
W”). They associate the program with W
("spraying of the dwellings”), W ("collection of blood smear”),
and WW (”giving free medicines for malaria”).

The ”bed net treatment” is another strategy launched recently by the Malaria
Control Service. The inclusion of this in the overall schema of malaria control is in

accordance with the global malaria control strategy of ”individual protection

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measures," formulated in the Ministerial Conference organized by WHO in
Amsterdam in October 1992. This strategy involves the "impregnation" (i.e.,
"soaking") of bed nets with insecticides.

I learned from an official at the provincial malaria control service that this
strategy has been introduced in various endemic areas in municipalities of the
province of Isabela, one of which is Cabagan. She informed me that Masipi is one of
the endemic malarial areas targeted to receive this intervention. She said that she had
instructed the sector chief for the district of Cabagan (which includes the
municipalities of Cabagan, Sta. Maria, and San Pablo) to do the initial step called
”social preparation.” This step meant informing the hatangay officials about the
intervention so that they could ensure participation by the people of the Way.
These officials, being the local representatives of the state and who are themselves
members of the "local elite," are expected to facilitate the implementation of state
programs, projects, and activities. Through them, state interests are articulated.

In Masipi, with services and other benefits from the state also comes state
influence. This influence is exerted through the public elementary schools, the
W health stations, and military detachments. In the area of health services, it
is the midwife who is directly involved with the villagers as she is the government’s
community-based primary health care worker. She is in charge of the haraagay
health station.

Disseminating Official Knowledge: Voices from Above
The ongoing antimalarial program has sponsored various interventions in

villages over the years entailing presentations by its personnel. In this case, a new

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strategy was being launched involving the application of pesticides to bed nets. In
many ways, the sociocultural configuration of this event is typical of health campaigns
that I observed in various settings over the last five years.

One Friday morning in March 1993, a team of seven malaria control personnel
arrived in Guingab from the Provincial Health Office in Ilagan, Isabela. The team
included the provincial malaria coordinator (hereafter, the coordinator), the
administrative officer, a microscopist, a sanitary engineer, the sector chief for the
district of Cauayan, the sector chief for the district of Cabagan, and a driver. They
arrived in Guingab in a vehicle; both sides of the vehicle had bold letters saying,
Philippine Health Development Program. This specific program is funded by loans
from the World Bank and the antimalarial program receives part of its support from
this program.

To the great dismay of the team, especially the coordinator, there was nobody
in Guingab but the m councilor and his wife. The team had expected a
sizeable number of villagers to participate. They were informed by the haraagay
councilor, however, that he had encountered difficulties in convincing villagers to
participate in this activity and had not succeeded because the villagers heard about a
child who had died after having been vaccinated by the local midwife. He felt that
their refusal to participate was due to that alleged incident. The villagers’ refusal to
participate marks their ambivalence and distrust towards government programs. This
also amounted to the councilor losing face, which he had to accept, realizing the
tenacity of people’s concerns. As a hmagay official, the councilor straddles two

worlds--that of his people and that of the government. He faces a double bind

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whenever the interests of the people and the government conflict.

The coordinator straightforwardly blamed the sector chief in charge of the
Cabagan district, saying, "This is poor social preparation. We came all the way from
Ilagan to help deal with the problem of malaria, yet it seems that the people here are
not interested at all.” The sector chief was very apologetic and suggested that the
team could possibly proceed to Magallones, where in his view the people are ”more
accommodating.” The coordinator acceded and asked the barangay councilor if it
would be possible for him to try once again to summon the villagers to come with
their mosquito nets later in the afternoon, so that the team, on the way back to the
provincial headquarters, could undertake the bed net treatment. The W
councilor agreed and, in an apologetic tone, said, ”Wen, QM” (”Yes, doctor”). I
note here the referential term, M, as an expression of deference to the
coordinator, whose position of authority is enhanced by the fact that she is a medical
doctor, a profession of high status and prestige in the area. Also, that deferential
treatment is reinforced as her subordinates publicly address her as d_okto_ra. In
directly reprimanding the sector chief in the presence of the harangay councilor, the
coordinator was not only able to assert their hierarchical relations, she also was able
to convey to the bataagay councilor her disappointment over the latter’s failure to
summon villagers to participate in the activity. In so doing, she compelled the
Dataagay councilor to try to make sure that when the team returned villagers would be
there. In deference to the coordinator, the councilor had to comply.

Arriving in Magallones, the team proceeded to the house of the k_agi_ta_n, the

head of the hataagay. Again, the coordinator showed a bit of irritation because she

101

was told that the Mag had left that early morning. She expressed a sigh of relief,
however, when she was approached by Mrs. Reyes, known in the village as konselaha
(female councilor). Kogehala, having garnered the most votes in the local election
of hataagay councilors, often takes over the role of the m in receiving visitors
from government agencies when he is not available. Kgnsehala welcomed the team
but said that she had been told that the team was arriving after lunch; thus the
villagers were not expected to assemble in the barangay hall until the early afternoon.
The coordinator apologized, said that the people in Guingab "were not ready," so the
team decided to proceed to Magallones.

As a gesture of hospitality, accorded routinely in deference to visiting
government officials, the kgnsehala, with assistance from the kapitan’a wife and the
local midwife, served some snacks (Coca-Cola and cookies) bought at a nearby gar—i-
fl: store and then lunch. This act of deference serves to reinforce the superordinate-
subordinate relationship acted out in this particular event. By virtue of her
professional status as a medical doctor and her government position as a malaria
control coordinator, the dam is able to assert her authority and power over her
subordinates, the Qataagay officials, and the harangay residents.

Meanwhile, the sanitary engineer, the two sector chiefs, and the driver
prepared the hataagay hall. They installed lines to hang up and dry the bed nets; set
up the microscope, bottles of antimalarials, and other paraphernalia on a table; and
placed the bottles of insecticides, basins, and pails in one corner of the hall. I note
here that the hataagay hall is a social space in which, frequently, official social

encounters such as this campaign take place. The holding of this campaign in this

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social space provides further legitimacy to the dominant position of the state’s
program actors over the local population. This asymmetrical relationship is further
reinforced by the fact that the program actors drew upon the local power resource,
namely, the haraagay officials, who, as I indicated earlier, are themselves members of
the local elite (the Mag).

After lunch, I talked with the team about the responses of other communities
to this particular control strategy. They expressed their disappointment over the
minimal participation. The coordinator pointed to two major reasons: the first being
"wrong timing,” that is, that the villagers were busy with farm work, and second, that
the people were fearful of the effects of the insecticide on their well-being, especially
that of their children. This suggests that the coordinator is aware of the reasons that
people refuse to participate in the program. And, it is this reality of people’s refusal
to participate with which the program has to contend.

At this point, the coordinator expressed her concern over the inadequacy of the
health education component of the program, to which she partly attributed the lack of
participation. In her own words, "We have to educate the people about the program,
especially its advantages, so that the people will change their attitude. " At the same
time, she pointed out the shortfalls of the health system and said, "The problem is
that there is lack of coordination between the Rural Health Unit and the Provincial
Malaria Control Unit. Often, the local midwife is not even present when we visit the
bataagay, so I am glad that Lorna [the midwife assigned in Masipi] is here to assist

us. These views of the coordinator reflect the politics of coordination within the

health care service itself. In a certain sense, the coordinator openly recognizes that

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part of the problem in drawing participation rests on the manner in which health
workers interact among themselves.

Moreover, these criticisms expressed by the coordinator suggest that the state
health workers themselves do not necessarily maintain an uncritical attitude towards
the antimalarial program. But this critical attitude seems to be directed mainly
towards program implementation. In other words, the antimalarial program workers
seem to be in agreement as to the goals and orientation of the program,24 which they
have to disseminate.

As another example of assertion of authority, the coordinator confronted
Lorna, the midwife, about the claim of the councilor in Guingab that the villagers
refused bed net treatment because of fear as a result of a child’s death after
vaccination. The midwife was stunned, expressed ignorance of the incident, and said
that she would look into it by talking to the barangay councilor. The coordinator then
expressed her appreciation of the midwife’s assistance in the campaign and asked her
if there would be a good turnout of people with their mosquito nets. With hesitancy,
the midwife told the coordinator that she hoped that many people would attend,
despite "the short notice that they had gotten from the sector chief. " Here, Lorna
alluded to the need for a sufficient amount of time to mobilize the people. In saying
that they had to mobilize people on ”short notice," she indirectly criticized the team’s
sense of coordination. As a subordinate, she was able to express subtly her

resentment against being ordered to recruit participants instantly.

 

24A caveat is in order. I am not suggesting that the workers, given their ethnic
backgrounds, do not hold ideas about, say, the etiology and treatment of malaria that may be
contrary to the prevailing biomedical explanations.

104

The villagers began to assemble in the Maggy hall around two o’clock in the
afternoon. A number of women and some children were waiting near the hall when
the team arrived. For each mosquito net, the microscopist recorded the name of the
owner, the size of the net (single or double), and the material of which the net is
made (nylon or cotton). The driver put tags on each of the mosquito nets, indicating
the number assigned to the owner. The two sector chiefs and the sanitary engineer
prepared the solution and vessels in which to soak the bed nets. The bataagay
midwife assisted the microscopist in collecting blood smears, which were examined,
right then and there, by the latter. The sector chief for Cabagan assisted in collecting
blood smears later on. The coordinator and the administrative officer took charge of
”educating” the villagers about the campaign. It appears that the team was guided by
a clear division of labor, which itself indicates their hierarchical relationship, that is,
aspects requiring technical knowledge were taken care of by the coordinator and the
administrative officer while the actual soaking of bed nets was carried out by the
driver, sector chiefs, and the sanitary engineer. More importantly, the team projected
the image of an organized group of government health workers, whose agenda was
that of delivering a health program to ensure the well-being of the community. They
represented, in short, the helping profession or the so-called civil servants supported
by the state. In the context of state-community relations, thus, the concept of
"helping” turns into a political statement that ultimately bolsters the image of a
benevolent state.

There were about 20 adult villagers and 10 children in the May hall when

the coordinator and the administrative officer embarked on their task of informing the

105

public about their agenda. The rest of the team members were carrying out their
routine tasks. While the campaign was taking place, other villagers, some of whom
were from Compra, entered the hall. The coordinator and the administrative officer
stood in the center of the hall facing the villagers seated on the bleachers.

For a while, some children were playing in the basketball court adjacent to the
hall as the campaign was taking place. The game was put to a halt by the barangay
treasurer, who said that their game was interfering with the ongoing meeting and
scolded them, "Awan babain dagitoy nga ububbing" (”These kids are shameless”).
This gesture of the barangay treasurer signals his authority but, at the same time,
declares publicly the value given to deference and demeanor by the villagers,
especially in the face of outsiders (in this case, the "visitors" from the Provincial
Health Office). In doing so, the pagagay treasurer not only was able to assert his
position of power in the village, but he also was able to extend his deference to the
government health workers, particularly the coordinator.

An examination of the discourse among the program actors and the villagers

provides a clear picture of the dynamics involved.” What follows is a complete

 

25The following symbols were used in the transcription:
C for the coordinator
A0 for the administrative officer
M for the microscopist
BT for My treasurer
K for the kgnsehala
AU for the audience
MW for the midwife
SC for malaria sector chief
Ellipsis (...) for pauses
Bracket (0 between lines for overlaps or interruptions
Italics for the English words and medical terms
Capital letters for a marked increased in loudness or emphasis
Underlining for Ilokano terms

106

transcript of a malaria campaign undertaken in the study area. The subheadings

reflect the key cultural themes marking the encounter.

m Pagigipation Needed

The coordinator took control of the meeting and expressed her expectation of
greater community attendance in this campaign. As I noted earlier, the baaagay
officials are expected to mobilize their constituents to attend government campaigns;
thus, the coordinator publicly expressed that expectation to the kgaaehala.

How is everybody? Where are the rest?

ngtora, the people from Compra are probably on their way here now.
How about those who reside here?

They are coming kotora.

Get them to come. Is there a problem?

Some people are asking me, dgktora, if you will be giving away
moskiterg (bed nets).

My God, we are not giving away bed nets. (She laughs.)

Some don’t want to come because they say that it is shameful to show
their dirty moskiterg, their moskitero with lots of holes, they say it is
shameful. (She laughs.)

We don’t mind if the nets are dirty, we are supposed to soak them in
insecticide.

Q

The coordinator spoke Tagalog throughout the campaign. She did not know
Ilokano, the local language. Very few people in Masipi understand Tagalog.
Another feature in the campaign is the frequent use of English words and highly
technical medical language which is also incomprehensible to nearly everyone. Not
using the local language hinders the communication process.

The coordinator demanded greater participation ("Where are the rest?”)

through expressing concern over the villagers’ life situation ("How is everybody?"),

 

Parentheses to enclose translations of local terms, clarifications of certain points in the
discussion, and nonverbal forms of communication such as laughter and murrnuring

107

an orthodox strategy of persuasion. Her demand, of course, rested on her authority,
which in turn rests on her status as a government representative and a medical doctor.
That demand was, of course, reinforced by the konsehala’s assurance that more

villagers were expected to attend ("They are coming, doktora"). The konsehala

 

attempted to explain the lack of participation by pointing out the shame involved in
"making public" dirty bed nets, and the expectation of free distribution of bed nets.
Yet, the coordinator ignored those concerns as she dismissed them outright (”My
God, we are not giving away bed nets”; ”We don’t mind if the bed nets are dirty").
Instead, she asserted their primary aim (”We are here to soak them in insecticide").
Thus, at the outset of the encounter, the coordinator was able not only to assert her
dominance, which was reinforced by the konsehala’s submissive stance ("They are
coming, m”), but also to establish the submission of those present.
Mam Control and Economic Pram

At this point, the coordinator glanced at the administrative officer, who
immediately handed to her a bunch of brochures, containing information about the
program and its activities. The brochure was written in Tagalog and had pictures
depicting activities in the control of malaria. The coordinator and the administrative
officer distributed the brochures to the villagers. Some members of the audience
showed a degree of enthusiasm by opening the brochure and reading aloud some
portions in the text. Others, however, browsed through it, folded it, and put it aside--
a gesture indicating a sense of disinterest, inability to understand Tagalog, or
illiteracy.

C: We are here to tell you something about our malaria program. We

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have some brochures here Could you help me distribute? OK,
let’s begin. (Reading the brochure) Malaria is a kind of disease caused
by microbes transmitted by mosquitoes. How does malaria deter
economic progress? Many of those victimized by malaria are those
within the age range when they are most productive and needed by the
nation Do you have any questions regarding this statement?

AU: (silence)

C: Don’t you ask yourselves why many of those victimized are of the age
when they are most productive? Don’t you ask why the children and
the elderly are not affected? Why are the active people the ones
afflicted with malaria? Isn’t this an important question?

AU: (murmurs)

C: Ahh, so you are now starting to think. Why do you think this is the
case? Whatever is in your mind answer me. Why do you think this is
so? Because they are the ones I hear some murmurs You just
don’t want to share, so people like you, your age, are the ones afflicted
by malaria

The use of the brochure lent formality to the encounter. More than that, the
brochure not only signalled the authoritative knowledge, on which the information
being disseminated hinged, but it also enhanced the position of authority the
coordinator had already assumed. In her attempt to connect with the audience, she
took an interrogatory tone ("Could you help me distribute?”; "Isn’t this an important
question?"; ”So you are now starting to think”). Obviously, she recognized the
silence of the audience.

Her exhortation that malaria impairs people "needed by the nation” resonates
with the idiom that ”malaria blocks development,” the state’s principal justification
for the institutionalization of this disease control program. Thus, since the people of
Masipi are affected by malaria, it is incumbent upon them to take malaria control
seriously. It appears, however, that this gesture is only remotely understood by the
local population and is predicated on the assumption that local concerns are

compatible with the national concerns. In my view, the silence of the audience to the

109

coordinator’s urging for a response (”Do you have any questions regarding this
statement?”) suggests that there is a gulf between local and national concerns.
ntractin M ' and Ev d R inns
Having introduced the idea that malaria is transmitted by mosquitoes, the
coordinator called attention to how day-to-day activities put people at risk:

C: because most of you are the ones working; you do the laundry, you
move from place to place. You move from place to place. You go to
the river to wash clothes. Your spouses to go to the field to work--
work in the field, plow, plant corn. Then, your children, the
teenagers, whom you ask for help, they are also affected, because they
move from place to place. Now, the question that you can ask me is
why is it that in our place there are no cases of malaria. But when
your kids went to other places, they were afflicted with malaria upon
return. That is the main reason why your age group is the one afflicted
by the disease because you move from place to place. For example,
Mrs. Reyes went to Compra. Somebody there upon her return if
she was bitten by a mosquito with malaria, upon her return malaria has
been observed. Do you understand?

AU: (silence)

C: OK. So this is what happened to cause people to get sick in the m
(village). So it is possible to be a cynic (pilosgpo)--Why do you come
here? Or, why do you come here when malaria doesn’t exist in our
place?--There are people like this.

By linking malaria transmission with daily activities, and by specifically citing
the konsehala’a routines, the coordinator tried to impart a sense of urgency for the
people to take the problem seriously. In order to obtain approval to her stance, she
asked the question, "Do you understand?”--a strategy commonly employed in
pedagogical encounters. The coordinator took an aggressive stance by outrightly
labeling people who would question her ideas as "pilosopo or cynic.”

It should be noted that all of Masipi is endemic with malaria. To suggest that

the people in Magallones get their malaria from Compra is thus a mistaken notion.

110

Considering that the flight range of the mosquito vector is two kilometers (Cabrera

and Arambulo 1977) and that the distance between Compra and Magallones is less

than a kilometer, the coordinator committed a considerable error in saying that

malaria is not endemic in Magallones. This mistake may well be due to the fact that

the members of the team, except the sector chiefs, were visiting the area for the first

time.

Surveillance ar_id Submission

AU:

To continue, the coordinator took up the topic of blood examination:

Because you go to places that we call endemic. This word means these
are the places where many cases are found. There are many malaria
cases because through blood examination, blood smear examination,
this is what Mr. Ocampo (the microscopist) will do, if you submit
yourselves to blood smear, you will view this with the microscope. It
will show whether it is positive or negative. Positive means when
microbes are present. We don’t have to talk about those kinds of
microbes because it is difficult to talk about these matters in only one
day. The important point is to know what positive means what
negative means, because later on we will discuss the things that are
related to the examination, and the connection of the examination with
the microscope in our effort to avoid malaria.

(silence)

The use of a specialist’s language (”kinds of microbes"; "endemic") and

medical technology (microscope) further bolstered the image of the coordinator as a

bearer of authoritative knowledge. By making the linkages among malaria, microbes,

and blood, the coordinator rationalized, if not strengthened, the on-the-spot

surveillance ("blood smear examination, this is what Mr. Ocampo will do, if you

submit yourselves to blood smear”).

111
“in H ’ n i N

The coordinator, at this point, challenged local understandings of malaria:
C: What are the misconceptions regarding malaria? Malaria is not caused

by drinking dirty water. I say this time and again wherever we go, that

you cannot get malaria from dirty water, because many people still

believe that malaria is due to drinking dirty water. I don’t say that you

won’t get sick from drinking dirty water. Yes, you can get sick from

drinking dirty water. For example, you drink the water in your well,

but it’s very dirty, there are fallen dried leaves, there are worms, these

worms multiply. There are microbes there. But if you drink water

from there you don’t get sick from malaria; rather you will get stomach

problems. Here we have dysentery, cholera, typhoid, that which we

call gastroenteritis. So, you still get sick but it is not malaria.

AU: (silence)

Here the bone of contention is the local conception of malaria causation
("drinking dirty water”). In contesting local knowledge about malaria and its modes
of transmission, ("Malaria is not caused by drinking dirty water. I say this time and
again wherever we go, that you cannot get malaria from dirty water”) the coordinator
dismisses local knowledge as "misconceptions” and tries to advance scientific
knowledge (”But if you drink water from there you don’t get sick from malaria;
rather you will get gastroenteritis. So, you still get sick but it is not malaria").
However, as discussed in Chapter Four, the local conception of malaria causation is
embedded in the logic of pollution and contagion and humoral pathology. Despite the
coordinator’s public denigration of deeply entrenched local conceptions, the audience
remains silent. l interpret this silence, which punctuates the course of the encounter,
as signaling the audience’s tacit awareness that they are to submit or appear to submit

in the face of authority. As I have noted earlier, the very arena of interaction (the

Dataagay hall) and the lecture method of communication, typical of a classroom

112

setting, encourage the audience’s subordinate posture.
M 'I C ! 'l

The coordinator called attention to the connection between mosquito and
malaria:

C: So WHAT YOU SHOULD STICK INTO YOUR BRAINS IS THAT
MALARIA REALLY COMES FROM MOSQUITOES. So if it comes
from the mosquitoes, so what we should attack is the mosquito. There
are three things--the mosquito, the individual bitten by the mosquito,
and the place where the individual lives; if one of these is eliminated,
malaria will disappear. If the mosquito disappears, malaria will
disappear. If you all disappear, then malaria, in turn, will disappear.
If there are no breeding places, the breeding places, malaria will
disappear. So these three are MAQKASABWAT ("in connivance").
The mosquito, the individual, and the place you live in. So these three,
it is sufficient for you to understand what to do to the individual, to the
mosquito, and what to do to the places where mosquitoes are found, or
to the breeding places. 80? Do you understand the point? DO YOU
HAVE ANY QUESTIONS?

AU: (silence)

C: If you do have, if the doctor is not clear, ask me, even in Ilokano,
Ibanag, or whatever, many here could speak Ilokano fluently.

AU: (silence)

The coordinator drew on epidemiology as she underscored the interaction of
the human host, the mosquito, and the parasite in the occurrence of malaria. Her
dominative stance was clearly exhibited in her insistence that malaria comes from
mosquitoes (”WHAT YOU SHOULD STICK INTO YOUR BRAINS IS THAT
MALARIA REALLY COMES FROM MOSQUITOES"). Obviously, she wanted the
audience to internalize this logic in dealing with malaria ("So if it comes from the
mosquitoes, so what we should attack is the mosquito”). What is ignored here,
however, is the embeddedness of malaria in the local conceptions of the interaction of

bodily processes, everyday routines, and other elements, including the spirit world, as

elucidated in Chapter Four. Perhaps the coordinator realizes that her use of Tagalog
is causing, in part, the silence of the audience. Thus, she invokes the ability of some

members of the team to translate into the local parlance what she is trying to convey

113

(”If you do have, if the doctor is not clear, ask me, even in Ilokano, Ibanag, or

whatever, many here could speak Ilokano fluently"). And, again, the coordinator

employs the pedagogical strategy that exudes an air of condescension ("80? Do you

understand the point? DO YOU HAVE ANY QUESTIONS?").

Which Mosguito?

BT:

treasurer. Her response was patronizing ("Treasurer is right!"). Villagers defer to
the treasurer because they regard him as one of the lakkalay (village elders); thus, the

treasurer’s statement (”There are many types of mosquitoes”) broke the silence and

At this point, the coordinator focused attention on the types of mosquitoes:

There are many types of mosquitoes, one of which has a big mouth.
When it bites, it is very itchy.

Treasurer is right. Actually, the mosquito, IN TRUTH, the mosquito
that malaria comes from is one of 4,300, 4,200 to be exact. I am not
familiar with those 4,000. The whole afternoon will be wasted if I
have to enumerate all of them. What is important is that the mosquito
that transmits malaria is called Anopheles flavirostris. The mosquito
that the Treasurer was talking about whose bites are painful and itchy,
you can really feel the itch to the bone. This mosquito is culex. It
comes from dirty water. Those that come from canals, those coming
from, what do you call them, for example those that come from the
artesian well, or from toilets, the water overflowed, these mosquitoes
are called culex. I am not saying that this mosquito will not cause any
illness. It can also bring illness, if you are bitten frequently. It brings
Japanese encephalitis, but most of the time, Filipinos are not affected,
through God’s mercy However, it is not this mosquito that carries
malaria. Later on, we will talk about what time the malaria mosquito
bites us.

To the delight of the coordinator, she was able to catch the attention of the

114

his response has provided greater impetus for the coordinator to move on with her
project of disseminating scientific knowledge to a rather passive audience.
P ’ -Mos ° nn i 11

At this point, the coordinator dwelled on how malaria is acquired:
C: 80 now. How do you get sick with malaria? You get sick with

malaria if you are bitten by a type of mosquito that carries microbes.

In science, this is called plasmodia. So that’s that. That is the name of

the microbe. This microbe is transmitted to an individual bitten by the

mosquito.
AU: (silence)

Here is another instance in which the coordinator takes a pedagogical stance.
To reinforce her assertions, she grounds her claims in the sphere of scientific
knowledge ("In science, this is called plasmodia”). In emphasizing plasmodia as the
ultimate cause of malaria, the coordinator establishes a framework in which local
notions of malaria causation are not to be considered. As elaborated in the previous
chapter, the Ilokano view of illness causation is embedded in a sociomoral matrix, in
which personal conduct (kinatao), notions of the body (naturalesa, humoral pathology,
sawiri), and relations with the spirit world figure prominently.
Deciphering and Treating Malaria

True to her profession as a medical doctor, the coordinator directed attention
to the clinical signs of malaria and the ”best" way to deal with malaria:
C: What are the signs or symptoms of malaria? First, we get shivers and

chills; secondly, high and recurrent fever, severe headaches, profuse

sweating, weakness and paleness. These are the usual symptoms of

malaria, but this does not mean, for example, that when someone gets

sick at home and exhibits chills or shivers, headaches, that malaria is

always the cause. I am not saying this is always the case. Because

these are also symptoms associated with other illnesses such as
influenza, what we call tflngkaso, has the same symptoms. What is the

115

best way if there is a member of the household, a relative, a sibling, or
a neighbor, who is feverish or shivering--what is the best we can do?

AU: (silence)

C: The best we can do is to go to the nearest barangay health station, to
Lorna, and tell Lorna the symptoms that your family is experiencing so
that a blood smear can be done That is what you are supposed to do
right away, take it for the doctor to examine; if he is not there, the
midwife or nurse. After Lorna has referred you to the appropriate
individual, she can inform the rural malaria coordinator, Mr. Lapus.
He can come here, or Lorna can get your blood smear. That is, the
pricking and then examination under the microscope. You have nothing
to lose if you get examined as soon as possible. Whether the cause of
his or her fever, headache, and shivering is malaria or not, if the
examination does not show malaria, you will be given what we call
presumptive treatment. If it was positive you will be given a radical
treatment. That is that. You will have a lot of medicines to take in a
week.

The coordinator’s status as a medical doctor was markedly shown in this part
of the encounter, as she spoke about malaria’s signs and symptoms ("but this does not
mean that when someone gets sick at home and exhibits chills or shivers,
headaches, that malaria is always the cause”) and the "best way” to deal with malaria.
What this posturing presupposes is people’s submission to the health establishment
("That is what you are supposed to do right away, take it for the doctor to examine; if
he is not there, the midwrfe or nurse"), including its medical regimen ("After Lorna
has referred you to the appropriate individual, she can inform the rural malaria
coordinator, Mr. Lapus. He can come here, or Lorna can get your blood smear”).
This posturing not only privileges biomedical knowledge and practice over local
knowledge but also moves the locus of decision making from the home to the health
establishment (”You have nothing to lose if you get examined as soon as possible";

”You will have a lot of medicines to take in a week").

116

M F M : T i
In this part of the encounter, the coordinator stressed the dreadful character of
malaria:
C: So we will continue Why should we dread malaria? Why do you
think so? Don’t look at the LqLigg (referring to the brochure). Why
do we have to dread malaria? Because if you get malaria, what will
happen to you?
BT: We will get sick.
C: RIGHT. Your lives will be ruined Malaria is fatal. That is what

you are not able to comprehend. Your earnings will get depleted
the savings from your livelihood for your hospitalization. Why
should we dread malaria? This can be transmitted by the mosquito to
the people through bites and can be transmitted quickly. So, this is
different from other illnesses. These can last for months, two months,
three months. They will last, but can be cured. Malaria gets serious
very easily. It quickly goes to the liver, the spleen, the brain. That’s
that. It damages the brain, the liver, the spleen what we call
cerebral malaria. Because we find blood formation in the liver and
bone marrow. That is that. So if malaria attacks these parts--if in the
brain, sometimes, if someone recovers, that individual who had malaria
in the brain, he gets tililling (Tagalog for ”mentally derailed”) or
seven_seveaseven (another expression for ”mentally derailed”). That’s
how it is. It’s a pity. If an individual gets this affliction, it is such a
pity; what will happen to his life? He won’t be able to work. Of
course, because we are Filipinos, when something like that happens in
the family, it becomes an embarrassment. So let us avoid getting
afflicted with this illness. Then, it goes to the liver and the spleen
malaria can cause death, if we don’t quickly get medical attention. I
have said this earlier.

The coordinator’s statement was replete with ideas designed to call attention to

malaria as a scary disease ("Your lives will be ruined Malaria is fatal"). More

specifically she employed scare tactics such as the disruption of work and depletion of

family resources (”Your earnings will get depleted the savings from your

livelihood for your hospitalization"; "He won’t be able to work"). This tactic was

made even more evident in underscoring the potential shame that cerebral malaria can

117

bring an individual and his family ("that individual who had malaria in the brain, he

gets tililing or savensevgagvgn It’s a pity when something like that happens in

the family, it becomes an embarrassment”). She enveloped these tactics with

paternalistic overtones, typical of a medical doctor ("So let us avoid getting afflicted

with this illness”; "Malaria can cause death, if we don’t quickly get medical

attention”).

W

At this juncture, the coordinator called attention to the biting habit of the

mosquitoes and the importance of protective measures:

C:

AU:

BT:

What is the other important information regarding the mosquito that
carries malaria? The mosquito that carries malaria bites between 6
p.m. and 6 am. What do we do when we go to sleep?

(a few women in the audience murmuring) Set up moskitero (mosquito net).
There! Right! That is why we are here, to get the mosquito nets that
you are using from six in the evening till dawn. Because the mosquito
that lands on your mosquito nets, of course, it lands on the mosquito
net first before it reaches you. If it enters inside When the
mosquito lands on your mosquito net, within twenty four hours, the
mosquito that landed on the mosquito net that was soaked in a gamot
(Tagalog term for medicine), K-Othrine later on, Mr. Reynoso
(the administrative officer) will explain to you the insecticide we are
using. It is important that this be explained to you clearly, that the
insecticide we are using is not hazardous. It can easily kill mosquitoes,
but not human beings.

Ma’am, l have a question. You said earlier that from 6 p.m. to 6
a.m., the mosquito net should be ready. For example, I am still out of
the mosquito net and then I am bitten during that time, what happens
then?

That’s it, OK, so. Bed net treatment is only one of the methods. Very
good question. Let’s thank him for his question. Let us applaud him.
(applause)

He is right, very good question. What if he is outside the mosquito net
at that time and the mosquito bites him? If bitten by a mosquito, you
will have symptoms, if you are bitten by a malaria mosquito, a
mosquito carrying malaria, that is why earlier I said that if you are
bitten by a mosquito, you will have symptoms. You should have a

118

blood smear immediately so you will get medical attention immediately
. One way to kill mosquitoes that carry malaria--aside from the bed

net treatment --there are other operations of the malaria control

program. Do you know what these are? Last year, was Leo Iapus

here?

AU: (with a beam on their faces, some members of the audience glancing at
Leo Lapus)

SC: (with a grin on his face and scratching his head, perhaps showing
embarrassment)

C: The other year, did he visit or not? Oh! Ieo, you are in trouble. Did
he visit? Wasn’t he carrying a spraycan? (She laughs).

AU: Yes. (laughter).

C: Oh! Yeah.

Crucial to the coordinator’s justification for the use of "impregnated bed nets"
is the idiom of protection against malarial mosquitoes. From her perspective, this is
enough reason for reconstituting a household item (i.e., the bed net) into an
instrument for malaria control.

In my view, this act of reconstituting the bed nets represents a form of control,
involving the regulation of people’s day-to-day practice (i.e., sleeping habits) in ways
that conform with mosquito control. It amounts to an intrusion of the people’s private
sphere, albeit veiled in the institutionalized idioms of prevention and control. To be
sure, bed net treatment, along with house spraying, involves another strategy of
shaping the social world of the communities affected by malaria, for it deeply
penetrates the domain of the household. The transgression of the most intimate
sphere of the household, thus, is integral to malaria control.

The pedagogical technique is made even more pronounced at this point of the
encounter, with the treasurer taking the role of a student (”Ma’am, I have a

question”), the coordinator that of a teacher (”Very good question. Let’s thank him

for his question. Let us applaud him”), and the audience that of students applauding

119

the treasurer upon the request of the coordinator.

Doubtless, by putting the sector chief on the spot ("Last year, was Leo Iapus

here?"), the coordinator was not only able to amuse the audience at the expense of the

sector chief. She was also able to subtly display her superiority to him in the public

eye.

foicial Malaria Control Meguros

In this part of the encounter, the coordinator directed attention to other

antimalarial strategies:

C:

AU:

C:

AU:

AU:

AU:

One of the ways to control malaria is the bed net treatment. Because
our target is what did I say about the three? The malaria the
individual or the environment, if we are using the bed net treatment?
The mosquito.
0K VERY GOOD. The mosquito. Let us turn to that question.
The environment. So what do we do? Mister (referring to the
barangay treasurer) is way ahead of us. Let’s just talk about it then,
before I forget.
(laughter)
Another way to avoid malaria is to be aware of the breeding places.
What is a breeding place in Ilokano?
Pagyaaan ("place of abode"), wajg ("body of water”)
I

Canal, rivers, like that? I am not saying
that you cover the canals, cover the brooks, the rivers, no. What this
means is that we should prevent them from breeding, from living there,
by clearing. Clear the areas around the brooks and rivers, the rivers
and the creeks. EXPOSE. Let us expose them to sunlight. Right? So
those who wash clothes and go to the edges of the rivers, tomorrow
bring with you your bolos and your knives. There. You clear the
surroundings so that there will be no

I
Yes.

I
THERE, RIGHT. That is what we call environmental
measures. So we attack the enemies of malaria through bed net
treatment, environmental measures and other biological measures . ..
The biological measures that we call--we from the malaria control--you
put in the breeding places, what we call--do you know what that is?

120

The small fish, you put them in places with water. Because they feed

on mosquito larvae. That is it. The eggs. They eat those. So this is

one way for us to kill the mosquitoes that bring malaria. So we have

bed net treatment, spraying operations, biological and also

environmental.

AU: (lively facial expression)

The infusion of humor into the ”pedagogical process” seemed to have livened
up the encounter, at this point. Yet, the encounter has increasingly become a
"classroom-like” situation, with the coordinator "testing” the extent to which the
audience has internalized information that she has been trying to impart.

So powerful is the pedagogical format that certain local cultural values are
muted. For instance, the idea of ”environmental measures" through clearing of the
streams where mosquitoes breed is a strategy that runs counter to local precepts about
the environment. The Ilokanos believe that they share the environment with "unseen
beings." They regard rivers, streams, forests, and so forth as places of abode of
environmental spirits. For instance, the al-alawig, a group of "mischievous spirits,"
inhabit the river banks, creeks, and streams. People who go to these areas are to
behave in specific ways to avoid the displeasure of the spirits. Cutting down the
growth on riverbanks would be a transgression against the spirits and could result in
illness and misfortune. The strategy of environmental engineering for malaria
control, thus, amounts to a blatant disregard of local knowledge. The program as

proposed, thus, from a local perspective, would jeopardize relationships to the spirits

that people endeavor to maintain in a harmonious state.

121
Lastilling A Sam af Qamm' y Rgmasibm ' y
In this part of the encounter, the coordinator advocated community
involvement in the antimalarial strategies advanced by the program:

C: So we are not the only ones responsible for successfully carrying out
the malaria control program. We may differ, but we should help each
other to eliminate mosquitoes and other factors that propagate malaria.
So we are not the only ones responsible. In the environmental,
environment, you live here. That is why you will find a way, won’t

you?
AU: (silence)
C: 0K. Let us continue talking about what we know about the mosquito

that carries malaria. The mosquito rests on the wall before biting
people. That is why we have what we call spraying operations. The
spraying, the sprayman, he sprays the walls. When the mosquito rests
on the wall, and your wall has been sprayed, it will die. Because your
walls had been sprayed. It won’t bite you anymore. Because it rested
on the walls before it hit you. That is the reason why we have the
spraying operations. That is it.

AU: (silence)

C: Now you understand why Leo Lapus comes around. And his aids, the
spraymen and canvassers. They spray your walls. You have to
cooperate because that is what we need. So it lands on the wall before
it bites This mosquito thrives in clear waters, and in slow-flowing
streams and creeks, as I said earlier. The mosquitoes that thrive in
dirty waters are not the ones that carry malaria. The mosquitoes that
carry malaria can be detected. That is that. Where they thrive, you
wouldn’t expect, because they are found in clear water. They are not
found in dirty water but in clean water. That is why we have to clear
(the streams), and let the water flow. If there are obstructions in the
river, there is a need, if possible, to straighten, straighten. Straighten
the flow, so as to facilitate the water flow.

In taking a humorous stance, the coordinator seemed to have established some
rapport with the audience, hence, acquiring attention to her ardent rationalization for
house spraying and environmental engineering. Also, with her enthusiasm went a
rather aggressive advocacy for community involvement in these activities ("So we are

not the only ones responsible for successfully carrying out the malaria control

122

program”; "You have to cooperate because that is what we need"). That cooperation
meant submission to and compliance with the state’s antimalarial schemes (”We may
differ, but we should help each other to eliminate mosquitoes and other factors that
propagate malaria"; "You have to cooperate because that is what we need”). The
audience, in turn, remained silent, like school children listening to their teacher’s
demand for attentiveness and submission.
Pe nl n Cllective Ii in

The subject at this point was individual and collective responsibility in malaria
prevention and control:

C: So how can we prevent and avoid the spread of malaria? We already
have answered this. We have to avoid the mosquito, use mosquito
nets, wear clothes with long sleeves--these are your protection. But I
ran into a cynic, where did I meet this individual? In Villa, I guess.
He said long sleeves? The hands (looking at her hands), it is still
possible; he is probably right, so the best way is to combine all the
ways that can kill the mosquito...
OK, you have to tie the big animals in the backyard. Why are we
asking you to tie the big animals in the backyard?

AU: So the mosquito can have a place to settle.

C: There. We do this so that the mosquito, instead of entering the house,
and biting you--right?--the animals will do. Do you have any
questions?

BT: How about this, dgiqara. There are those who don’t like the animals
(around the house), because it is the animals that draw the mosquitoes
around the houses.

C: (With manual gestures) Behind the house, like if this is the house, a
little further. Like this. There, a little further. Yes, this reminds me
of somebody who asked me if they happen to eat the animal, for
example a water buffalo, or a cow on which the mosquitoes feed, will
they get malaria? No, you won’t get malaria because it is the bite of
the mosquito that carries malaria. If you ate the malaria, the microbes
have already been digested. The malaria doesn’t pass through your
blood, you will digest the malaria and you won’t get malaria
OK, so eliminate the mosquitoes; how?

AU: (attentive expression)

C: As I already said, straighten and let the streams flow, you seed in the

123

rivers and streams larvivarous fish such as the t_il_api_a. So build a fish
pond here, if you are not too busy. Then make some fishing gear, then
invite me to go fishing.

(laughter)

I am just joking, to amuse everybody, right? All right, what is this?
(reading the brochure) Clear the streams. Oh, I have already said this.
You already know this.

The coordinator has a great deal of awareness of the prevailing problems

confronting the program. She thus anticipated potential resistance to the control

measures. Aggressively, she took up and dispelled instances of cynicism ("But I ran

into a cynic"; "Yes, this reminds of somebody who asked me”). In doing so, she

endeavored to preempt potential contestations from the audience. I view this move as

a way of muting the audience and thus maintaining control over the whole encounter.

This subtle form of domination was embedded in continuous joking (”I am just

joking, to amuse everybody, right?”).

Contesting Resistang to Huge Spraying

An effort was made to address the perennial problem of people’s refusal of

residual house spraying:

C:

AU:

BT:

BT:

Have your houses sprayed with insecticide. But don’t close your
houses when you see a sprayman--"That doesn’t have any effect. "
”The house will just become smelly.” But wow! Our spray is now
odorless, colorless, odorless, harmless; so what else could you ask for?
(attentive appearance)

But don’t you wipe it off, don’t you wipe off the walls for six months,
because if you wipe off the walls, the insecticide will be removed.
You know, glgktora, before, there were those who allowed DDT
spraying. It killed the chickens and the pigs.

No, this is powder, this is powder--F, I, C, A, M--Ficam. This is the
spray that we are using now; no, it is not a spray, I made a mistake;
this is powder that we mix with water which we use to spray. You
see, last year, it was done in a pilot area. A pilot area is where they
study the results. It turned out to be a success.

Do you have any explanation?

124

C: Answer that, Mang Tomas (name of the administrative officer).

AO: We don’t have, but this mix is for mosquitoes which have small bodies;
we have big bodies.

BT: Yes, as I said earlier, before so many people were affected.

AU: (showing greater attentiveness)

AO: That was in 1957.

C: That is right. Ficam, if it is not, what is deliberately in Tagalog?
(nobody responded) If not deliberately drank, intentionally drink
[Ficam], you won’t get poisoned. For example, if you happen to get in
contact with it by leaning on the wall, or you happen to put your
fingers in your mouth, you won’t get poisoned. This is considered
moderately hazardous, meaning that it is not poisonous like DDT. If
you intentionally swallow it, yes; but if you just lean on it, it is not.
Thus, K-Othrine is not hazardous. It makes you itchy a bit, though.

BT: You know ma’am, we are just asking.

C: That’s all right. We prefer that you do so, so that you can avoid any
hazard. When the kids wake up, of course you are also up by then.

So why would you allow your child to put the mosquito net into his
mouth? But if he puts the net inside his mouth, if it is the whole net--
which is impossible for him to do--he would be affected.

The coordinator was aware of the prevailing problem of refusal of DDT
spraying. In this part of the encounter greater effort was made to promote the
program, with the coordinator’s mode of speaking similar to that of radio and TV.
commercials (”Our spray is now odorless, colorless, odorless, harmless; so what else
could you ask for?”).

Moreover, what was striking here was the treasurer’s bold move to let the
team know about their unfavorable experience with DDT (”You know, go_k_t(fl,
before, there were those who allowed DDT spraying. It killed the chickens and the
pigs.”). The treasurer was echoing a prevailing concern of the villagers about the
hazards of insecticides. Thus, at this instance, he aligned himself with the villagers.

To dissipate people’s concern about the safety of the insecticide, both the

coordinator and the administrative officer had to make certain statements that, in their

125
view, would convince the audience. What struck me was the clever way of
suggesting that the ”mix is for mosquitoes which have small bodies,” and thus will

not affect humans’ ”big bodies. The power of this claim lies in its simplicity as it
draws on "common sense." I surmise that the audience would find this view
plausible. But what is ignored here is the complexity of people’s conception of the
body as exemplified by their notion of Maralesa and humoral pathology. Added to
this was the use of English words that are iconic of expert knowledge and prestige in
ways that suggest credibility. The use of English, here and elsewhere, thus represents
another powerful force in cultural domination.

Having sensed perhaps that the coordinator was taking great pains to persuade
the audience, the treasurer took a defensive role (”You know ma’am, we are just
asking"). By virtue of his use of the pronoun "we,” the stance of the treasurer
represents that of the audience as a whole. I regard this move as symptomatic of a
dilemma the treasurer faces arising from a conflict of interest--that is, taking the role
as a mouthpiece for the community and at the same time complying with his role as a
local purveyor of state programs and interests. As a power-broker, he strives to
please both parties. In the end, he reinforces both the coordinator’s paternalistic
stance ("That’s all right. We prefer that you do so, so that you can avoid any
hazard") and the submissive position of the audience.
WWW!

The coordinator began to conclude her lecture:

C: So OK after your house has been sprayed, have your blood examined

by the roving malaria canvassers from DOH, health center, district
hospital, and complete the drinking of the medicine, following the

126

advice of the doctor or the health worker. When told, "Misis (Tagalog
for a married woman), everyday, one tablet within a period of seven
days, within a period of five days, or within fourteen days," you have
to do so. Don’t, after drinking one or two, and then noticing that you
are feeling better, stop, and then think that you can put the rest of the
pills aside as reserba ("stored for future use"). Don’t think about
reserba. We have plenty of medicines. So 0K, submit yourself for
examination, let Lorna or Mr. Lapus do it, or come visit Ilagan, visit
our office, the Malaria Control Office, you are most welcome
OK so do you have other questions about this?
I

Mi: If you have questions, apt; (elders), if there
are parts in the lecture of dgktom, just ask so they can be answered.

MW: Don’t be ashamed, manang (elder sister).

Mi: Just ask. As they say: awan ti bain-bain ("don’t be ashamed”).

MW: So that things can become more clear.

M.

C

 

 

Oh yes. (laughing)

Mang Tomas and my other companions have something to say about

K—Othrine. All right, who will talk about the K-Othrine?

The coordinator once again displays her superiority by reiterating what they
are expected to comply with ( "So OK after your house has been sprayed, have your
blood examined by the roving malaria canvassers "). She exhibits her accusatory
effort of control by ordering the audience to get rid of their te_se_1;l_)_a mentality in
taking prescribed medicines (”Don’t, after drinking one or two, and then noticing that
you are feeling better, stop, and then think that you can put the rest of the pills aside
for future use or team. Don’t think about teaarba. We have plenty of medicines").
Her claim that there is sufficient medicine for the people is an empty claim since it is
common knowledge that the bgangay health station faces a lack of medical supplies.
Thus, in an encounter such as this where the audience is reduced to being subservient
listeners, the shortfalls of the health services are readily skirted.

True, there were efforts to encourage the audience to raise questions ("Do you

have any questions?”; ”Don’t be ashamed, manang (elder sister)"; "Just ask"). In this

127

context, however, these efforts are not entirely genuine. Participation would be

contradictory in this kind of a pedagogical encounter.

K-

hrine fe

The coordinator yielded the floor to the administrative officer, whose task was

to promote bed net treatment as a malaria control strategy. The administrative officer

spoke Ilokano, but he also used English and technical terms:

C:
A0:

A0:

All right, who is going to talk about K-Othrine?
What I will explain is this new method. You know, this malaria, it is
not only us, it is not only the government, who is responsible. You are
too. First, you have to protect your bodies. If you see a mosquito, kill
it right away. (He laughs.) Chances are, you just let the mosquito bite
you. (He laughs again.) It is important personal protection; kill
the mosquitoes. As dgkmra said, wear long-sleeved clothing and use
mosquito nets. And, for instance, if the problem is not so big, you
who live in this May can help. You can clear the streams and
creeks. Right? The government supports you by coming here to
collect blood slides, give you free medicine, and sometimes
hospitalization. That’s what the government can do. But don’t wait
until you get sick with malaria. All right? (He laughs again.) We
have a new strategy here. You know about house spraying, house
spraying, twice a year or just once, but not all parts of Cabagan are
covered. Only this mountainous area. You know about blood smear
collection for examination. And, the latest is this activity in which
maikan iti agaa iti mgakitg ya (”to put medicine in your mosquito
nets"). It’s just like spraying your houses. This K-Othrine, which we
will use later, is very moderately hazardous.
Moderately hazardous.
If you see an insecticide, they are labelled. if you see red, violet, like
that

I

yellow, orange
I
yellow, orange, green, if it is green, it is less toxic,
very moderately. Our mixture of K-Othrine is six to ten ml which we
mix with water. This K-Othrine that we put in your bed nets, when it
dries up, even if the children bite it, they won’t get affected, because
its active ingredients are not toxic, because it is only .001.5 to .002.5
[sic] per thousand liters, so it is not that much. If you drink this, of
course it will really poison you, but when you mix it with water, it is

128

no longer that poisonous. This mixture is 40 ml.

To establish his authority, the administrative officer reiterated the points that
had already been made by the coordinator. Undoubtedly, the administrative officer
faced a formidable task of dispelling doubts about the safety of K-Othrine. Thus, he
had to mobilize, once again, the idiom of personal and community responsibility,
which the coordinator had attempted to instill in the minds of the audience. He also
had to invoke the idea of a supportive government ("The government supports you”).
Yet, in dealing with the audience, the administrative officer also had to take a
dominative stance as he spoke in a commanding tone ("You have to”). In couching
this "new strategy” in terms of maikan iti agaa iti moskim ya (”to put medicine in
your mosquito nets"), the coordinator veils the toxic potential of pesticides even as he
emphatically claims that the insecticide is "very moderately hazardous."26

P le’s A nc

The administrative officer, here, was in the process of winding up his lecture
by going into details pertaining to the adoption of this control measure in the
community:

AO: You know this program, our program, we are supposed to turn it over

to the barangg. You will be the ones to do it; we are to instruct, then

you will do it yourselves. You just tell Mr. Lapus, you just tell him

which day you prefer, after six months, four to eight. You tell him the

day, you schedule bed net treatment, you tell Leo and so that they can

schedule their visit.

M: (Addressing the AO) How about its effectiveness, m ("companion”)?

A0: For instance, you have children who shit on it, which we can’t prevent
because they are our children; sometimes they also piss on it, thus, you

 

26This reminds me of Whyte’s observation about the semantics of medicine.
Drawing on her fieldwork in Uganda, she noted that the term medicine is construed
as a ”substance that transforms something--for better or worse” (1988:217).

A0:

A0:

A0:

A0:
BT:

A0:

129

have to wash the mgakitarg. But you have to dry it indoors; you air
dry it.
You should not put it under the heat of the sun; put it in a shaded
place.
Yes, in shaded areas.
Why? Because the chemicals will be destroyed.
Here (referring to the W hall), it can dry up, and even if you
smell it and put it next to your noses (showing actual act of smelling),
it is all right. The mosquitoes have small bodies. They don’t die right
away though. Their culicles, their feet are irritated because they get
into the poison, which gets into their bodies, it gets into their bodies.
They can’t live, within 24 hours, they die. They don’t die right in the
mosquito nets; you might look for them (he laughs); you won’t find
any.
The mosquitoes are paralyzed.
No, it is not toxic, the mosquitoes will just be paralyzed; this is a
stomach poison for the mosquitoes The mixture is--if you can
already do it--because we will be giving you this agg (medicine). It is
all right, pails are available, measuring cups too. Every mosquito net,
you mix 2.5 cc with 6 to 10 ml, just for a small mosquito net; so that is
the exact mixture.
I

Do you know what ml means? (directed to the audience).
milliliter, ahhh one liter, 1,000 ml.
cc before, it is now ml; you know, cc is ml now.
These two are the same.
One liter of water, that is equivalent to 1000 ml, yes. This, you should
not be afraid of, we are introducing this in the Cabagan district, but the
Cabagan district is no longer that malarious. It is better here, the
people have high intelligence, you know how to avoid malaria. If you
didn’t know how to avoid it, you would get it, and it is costly.
There are lots of positive cases here.
In Compra, there’s a lot.
(Talking to A0) Are you done with your lecture? (addressing the
audience) Do you have questions for Mr. Reynoso?
Do you have any questions?
You said earlier that the effect of the aga_s ("medicine," referring to the
K-Othrine) lasts for six to eight months. If you stop using the
mosquito net after a month, will the agaa still be effective?
This is what it is, the effect is continuous. The effectivity is eight
months. But we will come back. You tell Lorna or Mr. Iapus about
the day you are available so the medicine can be put in your bed nets.
Mr. Lapus will schedule this with you. Don’t wait for eight months.
After six months, you can do so. Every six months.
Every six months, we will come back.

130

BT: Every six months.
C: If this bed net operation becomes a success--what this means is that we

have to have data showing that, for example, we will see from the

feedback from the people if malaria increased or decreased or remained

the same. Time will come when we will just leave the medicine in

your place, and you will do this yourselves.

BT: Ahh, is that so?
AO: It is he, (pointing his finger at Mr. Iapus) Mr. Lapus. He will

supervise because we will not just give this (holding a bottle of K-

Othrine) to you. You might commit mistakes in using it. It might be

used for other purposes, not for the mosquito nets.

By giving instructions as to what is expected of the community in
implementing this control measure, the administrative officer (and, by extension, the
whole team) proceeded with a preconceived notion that there will be a community-
wide acceptance of the measure. The administrative officer was indeed banking on
the barangay to continue the program as he went into the details on how to undertake
bed net treatment and under whose supervision. With the treasurer inquiring about
the duration of effectiveness of the insecticide, a semblance of community acceptance
was lent to the ”new method."

Marking the closure to this encounter was the coordinator’s calling the
attention of the team about their commitment in Guingab. So they decided that the
sector chiefs, the sanitary engineer, and the administrative officer would pack up and
go ahead. The microscopist and the midwife continued collecting blood smears.
Based on the records, 35 bed nets were soaked and 50 blood smears collected. In
closing, the coordinator thanked the people who were there and expressed hope for
better attendance in future visits. In return, the kgasehala and the treasurer expressed

gratitude for the visit and apologized for whatever inconvenience the team may have

experienced-a gesture signalling once again the deferential treatment that local leaders

131
had to display in public.

The driver came to pick up the coordinator, the microscopist, and me at
around 4:30 in the afternoon and left for Guingab. There, the team did not conduct a
”public information campaign.” At least 30 individuals (adults and children) had
blood collected for later examination and a few bed nets were treated. The
"operations” were carried out in the front yard of the barangay councilor’s house, an
area where barangay-wide activities are usually held. Like the barangay hall, it is a
space where official meetings and government supported campaigns are commonly
held.

The campaign in Guingab was hurriedly undertaken in anticipation of the
three-hour drive back to the Provincial Health Office in Ilagan, the provincial capital.
Besides, the team appeared exhausted due to the amount of work they did in
Magallones. Snacks were served as the collection of blood smears and soaking of bed
nets were taking place. The coordinator and the administrative officer conversed with
the barangay councilor while they were having snacks. I believe that the acceptance
of the councilor’s hospitality by the team amounted to absolving the councilor’s
inability to summon people to participate earlier that day. Of course, that hospitality
also signalled a concrete act of deference.
anguding Ramarks

Viewed overall, the whole encounter reflects the dynamics of power in the
arena of disease control. By drawing on the baraagay as a power resource, the team
was able to advance their work in malaria control and in the process displayed their

authority and control over people’s lives, albeit bound by time, that is, at the moment

132

of the encounter. True the team drew deference from the people in the barangay, and
thus, asserted their power over them. Yet, in following the protocol of going through
the "office of the batangay,” they reciprocally reinforced and legitimized the position
of power of the bataagay officials. As I earlier noted, this situation puts the barangay
officials in a dilemma as they have to reconcile the interests of the state with the
interests of their constituencies. Given this situation, the subordinated villagers are
silenced in the face of the powerful. This is not to say that their interests are left
unarticulated; rather, their concerns are often laid out in the open and then dismissed
as ”misconceptions” simply because they run the program’s cultural schema.
Moreover, inscribed in the encounter is the state’s logic of economic
development. The coordinator’s exhortation that the people are ”needed by the
nation” reflects the dominant ideological underpinning of the malaria control program.
To participate in malaria control, thus, is a moral obligation, to which the program
insists the people should subscribe. The interests of the state, however, do not
necessarily concur with local interests, and the conflict is implied by the characteristic
responses of the people to the program, responses which are guided by their
understandings of malaria in relation to their sense of health and well-being.
Contributing to the structuring of the negotiation of meanings is the May
hall, which called for a passive demeanor on the part of the villagers. This
structuring is complemented by the deployment of techniques of persuasion (e. g.,

humor, the authoritative language of science, and pedagogical techniques).

133
Responses to the Malaria Control Program: Voices from Below

To explore further the interactions between the antimalarial program and the
Ilokanos, this section deals with the ways in which the people perceive and relate to
the program and its actors. Attention is given to what the people say and do outside
the direct observation of health authorities.

Ho r in

The program categorizes Masipi among what it labels as a ”hard-core"
malarious barangay in the municipality of Cabagan, given Masipi’s annual parasite
incidence of more than 10 individuals per 1000 population. Accordingly, Masipi is to
be subjected to residual house spraying twice a year by a team composed of a "squad
leader" and his ”spraymen. " They are referred to by the municipal health officer as
”malaria boys." This team is guided by the principle of "total coverage," that is, the
team should not leave any dwelling unsprayed. Their performance is evaluated in
terms of whether they have met the targeted number of dwellings to be sprayed.

According to the sector chief, whose task is to supervise the spraying
operation, the boys follow "s.o.p.” ("standard operating procedure”). Initially, the
MEL“ is personally informed by the sector chief a few days before any spraying
activity takes place. In turn, the kapitaa orders the barangay councilors to announce
the activity to their respective ml; (a neighborhood). These paro_k are divided
among the councilors for closer control and supervision. Making the May
structure the link between the community and the state health care services, local
health officials contend, was an effort to ensure the cooperation and participation of

the villagers. This s.o.p, however, has proved ineffective, according to the sector

134

chief and the malaria boys. They contend that prior notification of house spraying
only leads to a situation in which some villagers leave their houses on the scheduled
day to avoid spraying. Thus, these houses are left unsprayed.

How is spraying perceived in the community? Asked whether the malaria
workers come to spray houses in the village with pesticide, the majority responded
positively (98%; n=100); most said that DDT was being used (80.6%; n=98). A
few (17.3%; n=98), however, did not know a name of a pesticide that was being
sprayed.

Table 22 shows the responses to a question about the purpose of house
spraying. The dominant view is that it is done to eliminate mosquitoes. There are
claims that spraying gets rid of pests other than mosquitoes and that it removes venom
(djta) carried by mosquitoes. A few did not know the purpose of house spraying, and

some commented that the spraymen had not bothered to tell them.

Table 22. Purposes of spraying

 

no. %
To get rid of mosquitoes 57 58.1
To get rid of mosquitoes that bring malma 16 16.3
To remove venom (d_ita) in the mosquito 10 10.2
To get rid of mosquitoes, flies, cockroaches,
or ants 10 10.2
Do not know 8 8.1

 

n=98 respondents; percentages total to more than 100 because
of multiple responses per respondent.

135
The purpose of DDT has been locally reconfigured. The Ilokanos regard DDT

as quelling the v_en_Qtn_ in mosquito bites. It is also believed that DDT is meant to
eliminate the mosquito, which carry mgit (dirt), in line with their notions of pollution
in illness causation.

Respondents were asked about what they had been told by the spraymen
regarding the duration of the efficacy Mg) of the pesticide. Table 23 shows that the
majority (91.8%; n=90) were unaware that the residual effect of the insecticide lasts

for at least six months because the spraymen had not informed them.

Table 23. Duration of the efficacy of the pesticide

 

no %
Not informed 90 91 .8
Less than 1 week 2 2.0
One month 2 2.0
Two to three months 2 2.0
Five to six months 2 2.0

 

n =98 respondents

Asked whether their houses had ever been sprayed, a majority responded
affirmatively (82%; n= 100). Tables 24 and 25 list the reasons respondents gave for
their acceptance or rejection of house spraying. I note here that aside from the
dominant rationale that house spraying is directed towards the control of the mosquito
population, the responses also indicated that submission to house spraying is

mandatory (30.4 % ; n = 82).

136

Table 24. Reasons that households submit to house spraying

 

no. %
To kill mosquitoes 47 57.3
To drive away mosquitoes
so we can sleep well 22 26.8

To get rid of mosquitoes

so they won’t transmit

illness 12 14.6
To get rid of mosquitoes,

flies, cockroaches,

or ants 10 l2.1
House spraying is mandatory 25 30.4

 

n = 82 respondents; percentages total to more
than 100 because of multiple responses per
respondent.

Table 25. Reasons that households refuse house spraying

 

no. %

Repulsive smell of DDT 10 55.5
House is newly built 5 27.7
The smell makes chickens

dizzy and they die 4 22.2
Children are affected by

the smell 4 22.2
Pets die 3 16.6
Wife just gave birth 2 11.0
Might contaminate bread

(bakery) 1 5.5

 

n =18 respondents; percentages total to more
than 100 because of multiple responses per respondent.

137

What appears to be a widespread acceptance of this control measure, however,
should be appraised in relation to the practice of washing off areas sprayed with
DDT. A majority (76.8%; n=82) washes off the pesticide because, as shown in
Table 26, house spraying runs counter not only to the villagers’ sense of cleanliness
but also their sense of safety and comfort, including that of their domestic animals

and pets.

Table 26. Reasons that the pesticide is washed off

 

no. %

Messes up the sleeping area 27 42.8
Messes up the kitchen 25 39.6
Children might touch and

ingest DDT 17 26.9
Leaves a nauseating smell 12 19.0
Leaves white spots on the floor

and the walls 12 19.0

 

h=63 respondents; percentages total to more
than 100 because of multiple responses per
respondent.

The practice of washing DDT off the walls and floor, in my view, reflects
ambivalence on the part of those who submit to house spraying. DDT spraying is
tolerated in that it quells the rugit and dita in mosquitoes. Yet, it is washed off
because it poisons their domestic animals, soils their houses, and causes nausea. This

ambivalence towards DDT spraying allows the continuation of the malaria control

program in the area, despite outright resistance from some members of the

138
community.

Moreover, resistance by the people is reinforced by a common view that
questions the efficacy Mg) of DDT in wiping out Llimbabmg, the local term for
pests. A resident in his late eighties expressed this cogently:

Dagitoy nga alimbubuyog ket parte ti pagyanan isu gapu nga saan nga

mabalen nga ikatten ken iwasanen. Mabalen met nga matay da ngem

dagidyay mabati umadu da manen sadantu sumubli.

These pests are part of the environs so it is not possible to get rid of

them totally. While some may die, others would just multiply and then

would come back.

Others contend that part of the reason why the spraying is not effective is that
the malaria workers deliberately "weaken the mixture” (pakapsagn da ti timpla) by
adding more water to DDT. They argue that this practice enables the spraymen to set
aside insecticides to be sold to commercial farms outside the municipality. This
accusation suggests that the people are mindful not only of the effects of DDT but
also of the conduct of the spraymen. In fact, this accusation is so common that the
program officials had to institute measures to control the smuggling of insecticides.
The spraymen are now required to return empty insecticide packages for strict
accounting.

It could also be said that the smuggling of pesticides is symptomatic of the
problem of corruption, which is popularly referred to as pamgkutakot, pervading the

government service. Some informants, however, justify paaagkurakgt as a way of

augmenting the very low salaries health workers receive from the government.

139
Mmding

Another control strategy, referred to officially as case finding, involves
treatment of active cases of malaria through passive case finding (investigation of
febrile cases) and active case finding (serological surveys). The local midwife
manages the b_a_raagay health station and takes care of passive case finding. The
20-year-old midwife said that her role in the program is to routinely collect blood
smears from febrile patients visiting the station and she is also to give them a single
dose of an antimalarial drug as a presumptive treatment. These blood smears are then
brought to the Rural Health Unit at the pgblacion for examination by a microscopist.
In turn, the microscopist informs the midwife about the positive cases for treatment.

The malaria boys undertake active case finding. Technically referred to as
malaria canvassers, they are assigned a monthly target, a percentage of blood smears
per barangay population in the district. Thus, they periodically visit Masipi to collect
smears from the residents. It should not come as a surprise that, rather than
performing time-consuming house-to-house visits, the canvassers choose school
classrooms, public meetings, and even funeral wakes as settings for collecting smears.
This strategy allows them to meet their targets in a shorter period of time.

Results of the survey concerning this particular control strategy indicate that
about three-fourths of the respondents (77.3%; n=84) had, at one time or another,
participated in active case finding. We asked if the canvassers had promised to
inform them about the result of the blood test. The majority (84.6%; n=65)
answered no. The rest (15.3%; n=65), who answered yes, expressed some

disappointment because the canvassers did not fulfill their promise.

140

Respondents were also asked about the rationale for collecting blood smears.
Table 27 indicates that they see the collection of blood smears as not solely linked to
testing for mam. Rather, they associate it with the notion of "thin blood,” which
is construed as ”weak”; with the notion of "thick blood,” which is associated with
”high blood"; with a test for "blood type”; or with free medicines. Blood smear

collection is also viewed as a way to entitle participants to free antimalarial pills.

Table 27. Reasons for collecting blood smears

 

no. %

To test if we have m 53 63.0
To test if our blood is ”thin" or "weak" 20 23.8
To test if blood is thick or if one has

”high blood" 15 17.8
To entitle one to free medicines 6 7.1
To test your ”blood type” 2 2.3
I do not know, they do not tell us 3 3.5

 

n=84 respondents; percentages total to more than 100 because
of multiple responses per respondent.

Further probing on what respondents meant by "to test if we have mama”
and "to test your blood type” yielded a straightforward answer, "That is what we are
told by the collectors." These responses seem to suggest that the villagers recognize
the connection between blood smear collection and the presence or absence of
mama, viewed as a reified entity that resides in the blood. In a sense, this signals a
local accommodation of the literal meaning of ”blood smear" and ”blood type.” At

the same time, the purpose of blood smear collection has also been inflected,

141

following their notions of W ("thin blood") and aabangbang nga
m (”thick blood"). Locally, these are inborn qualities of the body and are

understood in terms of the notion of gaggle—5a,.

Others, however, have constructed the meaning of participating in blood smear
collection as obtaining free antimalarial drugs. I regard this view as rooted in their
experience with malaria canvassers who routinely gave away malaria pills in exchange
for blood smears.

D_L_ug Distribution

A common image of the tagamalma kongol is that they give antimalarial pills
m ("for free”). In a sense, the antimalarial pills are iconic of the long-standing
links between the workers and the people of Masipi. The pills serve as a powerful
incentive for local participation in or submission to case-finding and house-spraying
activities. Free pill distribution made the malaria workers popular in the village. The
malaria workers use pills to establish rapport with the people in the community.
Frequently, villagers ask for antimalarial pills pata reserba ("for future use"), to
which requests the malaria workers usually accede. Officially, however, free
antimalarial pills are to be given only to those who exhibit clinical symptoms of
malaria such as fever and chills. At present, the workers no longer have access to
these pills, and it is now the midwife only who is authorized to give presumptive
treatment and, only upon instructions from the Rural Health Unit, radical treatment.
Moreover, the bamgay health station is left without an adequate supply of drugs,
including antimalarials. As a result, some villagers make such disparaging remarks as

"Awan met sibli da dagita; awan met ti agas nga ited da" ("They are useless; they

142
don’t have medicines to give").

The people’s responses to the program’s control strategies (i.e., house
spraying, case finding, and treatment) suggest that there is a pervasive feeling of
ambivalence towards house spraying. Apparently, the idea of controlling malaria
through eliminating the mosquitoes has been subjected to local interpretations. Many
allow their houses to be sprayed not only because it is mandatory but also because
they believe that it is useful in eliminating the di_ta (poison) and the r_ug_it (dirt) in
mosquito bites. Most villagers wipe off the insecticides afterwards simply because
spraying violates their sense of cleanliness, which, by extension, relates to their sense
of well-being. The ambivalence also stems from a common precept that mosquitoes
will always remain in the environment. With respect to case finding, people seem to
have mechanically subjected themselves to this strategy, because it sometimes allows
them to obtain free antimalarial drugs. However, the failure of the malaria workers
to provide free antimalarial pills has also caused a sense of skepticism about the
sincerity of the workers, and by extension, the state’s health service.

Community Participation

The strategy of community participation is predicated upon the Primary Health
Care (PHC) approach, which has been embraced by the Philippine government as a
member of the World Health Organization. As health officials put it, ”community
participation” is PHC’s cornerstone. As we have seen in the previous section, the
state is banking on the W to pursue its health agenda, an agenda that has been
designed and formulated independent of local ways of dealing with problematic life

situations. In other words, the state’s sense of community participation is one that

143

rests on what Riflrin (1985) refers to as the ”health planning approach," which relies
heavily on the expertise of health planners and policymakers in developing strategies
to make health services accessible to large numbers of people. Accordingly, local
communities are expected to get involved in plans of action designed by health
planners and policymakers.

How is ”community participation in malaria control" construed by the
Ilokanos? In addressing this question, we asked whether the residents can do
something to control mtatya. More than half gave a negative response (see Table

28).

Table 28. Whether the residents can control malma

 

no. %
Yes 42 42
No 55 55
Do not know 3 3

Total 100 100

 

144

Table 29 shows specific reasons given by 55 villagers for their inability to
control malagta. By and large, these reasons point to the close links respondents
make among everyday activities, work habits, mturaleaa, the environment, and

tnatatya. To these respondents, malaria control seems impossible.

Table 29. Reasons that villagers cannot control malatya

 

no.

People wash up even when they are
tired or after overworking 14
It is natural for people residing in a
mountainous area such as ours

to get sick with malgya 12
We allow our houses to be sprayed yet

mosquitoes still abound 12
Many villagers are prone to getting

sick because of weak paga‘alasa 9

We are surrounded by bushes and thickets,
where mosquitoes and other pests hide,
so mm remains 8
Malma just comes and goes 3

%

25.4

21.8

21.8

16.3

14.5
5.4

 

n=55 respondents; percentages total to more than 100

because of multiple responses per respondent.

145

Table 30 lists the activities that 42 of the respondents report they can do to
control mam. In examining the nature of these activities, I note that cleanliness
figures as a dominant value in the framework of action. This local framework signals
an obvious departure from the official malaria control schema. In recognizing the

merit in cooperating with program personnel in order to control malaria, however, the

people reaffirm the reason for the existence of the program.

Table 30. Activities that residents can do to control malaga

 

l’lO.

Residents should keep their houses,

toilets, and surroundings clean 16
Residents should cooperate with the

malaria personnel by submitting

to house spraying 15
Residents should cut the grasses

surrounding their houses to drive away

the mosquitoes 8
Residents should use mosquito nets 4
Residents should participate in

blood smear collection 2

%

38.0

35.7

19.0

9.5

4.7

 

n=42 respondents; percentages total to more than 100 because

of multiple responses per respondent.

146

We asked respondents whether government health personnel and the residents
should join hands in order to control malaria in the area. As shown in Table 31,
more than half answered affirmatively which, again, tends to suggest their sense of

openness to this government program.

Table 31. Whether health personnel and residents should become partners

 

no. %
Yes 56 56
No 39 39

No response 5 5
Total 100 100

 

Those who answered yes were asked about the nature of that potential
partnership, specifically, the activities and responsibilites they envision. These
responses are listed in Table 32. The predominant view is that the residents should
not only observe cleanliness, which is informed by the local logic of contagion and
pollution, but also conform to malaria control program requirements. They, however,
expect the health workers to carry out their responsibilities in controlling malaria--a
view that signals people’s dependence on the health services of the government.
Frequently, people’s dissatisfaction about the health care system is expressed through
personal criticisms directed at the frontline health workers (i.e., the midwife, the
sector chief, the canvassers, and the spraymen who get the brunt of criticism). These

workers, thus, serve as buffers of the state against people’s sentiments about the

147

inadequacies of the public health services.

Table 32. Activities of residents and health workers to control malaga

 

no. %

Residents should clean surroundings 15 26.7
Building toilets is necessary;

every household should have a

toilet 14 25.0
Residents should not refuse house

spraying 12 21.4
Health workers should supply

residents with malaria pills 12 21.4

Health workers should come

regularly to take blood samples to

find out whom to give medicine 7 12.5
Health workers should conduct

lectures on how to get rid

of melanin 3 5.3
Health workers should conduct

lectures on cleanliness and eating

nutritious foods 2 3.5

 

n=56 respondents; percentages total to more than 100
because of multiple responses per respondent.

148

Those who contended otherwise were asked why they reject the idea of
partnership. Responses to that question are listed in Table 33. These responses
underscore local awareness of cases of residents refusing house spraying, the
perceived inadequacies of the program, the shortcomings of the barangay officials,
and the notion that malaria is something natural, all of which shape the ambivalence

of local people towards the efforts to reduce malaria in Masipi.

Table 33. Reasons that partnership is not feasible

 

no.

Several residents do not cooperate;

many refuse house spraying 13
Malma is here to stay 9
Our My officials do not seem

to take the problem seriously 9
It is natural for people residing in

the mountains to get sick with

melanin 7
Oftentimes the health workers do not

have medicines to give 4
People take a bath even when they are

tired 2
There are still plenty of mosquitoes

despite house spraying 2

%
33.3
23.0

23.0

17.9
10.2
5.1

5.1

 

n=39 respondents; percentages total to more than 100 because

of multiple responses per respondent.

149

What emerges from the preceding discussion is a situation in which villagers
vacillate as to the merit of community participation in controlling malaria. In their
view, malaria is one illness that cannot be controlled, considering the conditions of
their existence--heavy farm work, weak naturalesa, and an environment that makes
them vulnerable to getting sick with malaria. Their idea of partnership with the
government to control malaria is one that underscores conformity with the program’s
activities. However, it is one that is not devoid of reservations as attested by their
ambivalent attitude towards house spraying.

The picture that one gets is that the people tend to reinforce a relationship of
dependency, with the health workers taking the sole responsibility of controlling
malaria and thus the people complying with the program’s requisites. Therefore,
notwithstanding their ambivalence towards the program, the villagers, ultimately,
reproduce the structure and orientation of the state-led malaria control program.

oncl ’ Remarks

In this section, I paid close attention to discourses and acts articulated outside
the direct observation of program actors. The reactions of the villagers towards the
program are constructed in terms of their actual experience with the program and
magma. The program has been incorporated into local consciousness but in a
reconfigured form that is in accordance with the local cultural schema (e.g., house
spraying, blood smear collecting). In addition, people’s ambivalence towards the
antimalarial program could be attributed to the reconfiguration of the meaning of the
cause of malaria, the mode of its transmission, and the strategies deployed to control

it; the negative experience of the people with DDT spraying; the local understandings

150

of ”community participation"; and the unfavorable views about the conduct of some
malaria control workers. The villagers, however, are not able to articulate this
ambivalence in their own terms in face-to-face interactions with health authorities
because such interactions are situated in settings that have been preempted by state
power. As indicated in the previous section, the batapgay officials play a key role in

the perpetuation of silence and passivity in the face of state authority.

 

Chapter Six

CONCLUSIONS

T h l ’ M ’ :
Tha Limits pf Cpltprgaj meination and Rm !

 

In addressing the interactions between the state and local communities in the
struggles against malaria in the Philippines, I drew inspiration from critical-

interpretive medical anthropology, which, as I have noted in Chapter One, begins

 

with the supposition that social discourses and practices are fundamentally
negotiations of meanings, and, by extension, are expressions of power relations.
Thus, l examined the convergence of two forms of struggle against malaria in the
Philippines—-the institutionalized malaria control program and the Ilokano
ethnomedical knowledge and practice with respect to malaria and the antimalarial
program itself--as an example of the inseparability of culture, power, and history in
the politics of disease control (cf. Comaroff and Comaroff 1992:28). I developed a
concept of cultural politics as an analytic device to examine the confrontations of
cultural schemas in social encounters involving different understandings of and
responses to reality. I viewed the predicaments faced by the state and the Ilokanos in
their struggles against malaria as expressions of cultural politics in the arena of public

health interventions.

151

152

Central to my analysis is an explication of the social context within which
these confrontations of cultural frameworks take place. The antimalarial program is
grounded in the state’s public institutions that hold varying degrees of coercive power
that sustain the superordinate—subordinate relationship between the state health
functionaries and the public.

From a dialectical perspective, that superordinate-subordinate relationship is
one of reciprocal interdependence (cf. Comaroff 1985:252). In this study, I took the
task of unraveling the nature of that relationship by interpreting the "truth" claims
borne of the cultural schemas deployed by the state health personnel and the Ilokanos
in confronting the problem of malaria. To achieve this task, I attended to situated
practices and discourses that reflect the culturally constructed ”multiple truths" about
malaria and its effects on individuals and society.

Fundamentally, these two forms of struggle are diametrically opposed given
their characteristic cultural logics. This situation, I believe, underlies the
contestations over the strategies to deal with the impact of malaria. What emerges
from these contestations is a process in which a state intervention such as disease
control, carried out by the state health care apparatus, is challenged by local cultural
forms, albeit expressed in diffused and inchoate practices.

The process of cultural domination inherent in the malaria program is always
subject to the constitution of the social arenas within which it takes place. Settings
such as the bataagay hall, where the hegemonic state power is implicitly inscribed,
legitimizes the dominant role played by health workers as they act as the mouthpiece

for the state agenda. Here, cultural domination is most forceful as the subordinated

153

group takes a passive role by the sheer presence of the state representatives. Passivity
in the face of authority could be viewed as an expected demeanor of the subordinated,
who, to begin with, were summoned to participate by their local leaders. To
challenge government authorities openly in the face of their leaders could mean
challenging the local leaders themselves. Passivity could also be viewed, however, as
holding back one’s dissent but expressing it in an appropriate time and place.

The practice of cultural domination in the antimalarial program is reinforced
by the Mgay officials, who collectively serve as a conduit between the state and
the community. As "power-brokers, " they perpetuate the patron-client relationship
between the state and its citizens. So deeply entrenched is this power relation that it
breeds deference to authority, a demeanor expected of the subordinated group. In
effect, the barangay and its functionaries contribute to the perpetuation of
superordinate-subordinate relations between the state-supported health workers and the
villagers, leading to an attenuation of the villagers’ sentiments and concerns over
certain aspects of the program.

A face-to-face encounter such as the bednet treatment campaign reflects the
display of a dominative stance, if not the outright denigration of local cultural
knowledge and practices by program actors. This open expression of domination and
subordination exemplifies what Scott (1990) called the "public transcript" of the
dynamics of power.

I also indicated the relative freedom of the subordinated to express themselves
outside the direct observation of the powerful by describing the ”offstage" practices

and claims of the subordinated. The local discourse challenges the efficacy of DDT

154

spraying, expresses disgust with malaria workers, who burden the community because
they have to be provided with meals, and defies the idea of community participation
because the program activities interfere with work on the farm and other daily
activities of the local people.

However, I hasten to add that the Ilokanos view the antimalarial program as
not totally detrimental to their existence. They assert their resistance by evading
house spraying, but they also take advantage of free health services and medicines
from the government. They are pragmatic enough not to reject completely the health
establishment. Thus, ambivalence towards the antimalarial program is a strategy that
allows villagers to either accept or reject aspects of the program, depending on their
assessment of the effects of the program on their daily lives.

Indeed, the state health functionaries are able to denigrate the cultural precepts
and practices of the Ilokanos by imposing the authoritative knowledge of science and
medicine. However, the Ilokanos are able to maintain their cultural integrity by
upholding a cultural schema that provides order and meaning to their day-today lives.
In practice, this cultural schema not only allows them to reconfigure the meaning of
malaria and its control, but it also fuels their reactions to the antimalarial program,
reactions that oscillate between conformity and resistance.

Because local resistance (whether expressed overtly through outright refusal of
house spraying or covertly through apathy) is expressed in a manner that is
unorganized and diffused, the people are unable to effect any changes in the structure
and orientation of the program. More importantly, these forms of resistance are

constrained by their articulation within a pataagay structure, which is an instrument of

155

state control. The strength of state control is bolstered by the presence of a military
detachment in Masipi, as well as other Maya in the militarized zone of the
Cagayan Valley.

Accounting for actual encounters and "offstage" discourse leads us to regard
power as residing in human dispositions and strategies and thus defies the
conventional view of power as simply acts of domination (cf. Giddens 1979). It is in
the best interest of the subordinate not to contest openly the claims of the powerful
because, ultimately, the cultural endowment of the powerful will prevail. At the same
time, the dominance of state representatives could be viewed as deliberate acts of
domination for, as "public servants,” they hold the view that they are delivering
services that will alleviate the sufferings of the people.

The Ilokanos have managed to appropriate creatively some biomedical
knowledge and technology associated with malaria in accordance with the practical
logic of their own meaning system. Biomedical knowledge about malaria (e. g., the
role of the mosquito vector in malaria transmission, key symptoms associated with
malaria, and treatment) has been reformulated in terms of Ilokano theories of illness
causation such as pollution, contagion, and actions of environmental spirits and the
spirits of deceased relatives. In addition, they combine locally based treatments such
as plant medicines and healing rituals with biomedically oriented therapies. This
characteristic response to malaria by the Ilokanos is guided by an ethnomedical
schema requiring therapy that has to uphold the synthesis of moral, social, and
physical presentations of sickness.

This localized view of malaria radically departs from that of the state, which,

 

156

given its adherence to biomedicine, denies the "essential interconnection of physical,
social and moral being, both in health and illness" (Comaroff 1982:58). Trapped in
this view of malaria, the state health planners and policy makers emphasize technical
solutions that revolve around the mosquito-plasmodia axis.

Consequently, this externally imposed, state-led schema of disease control
finds itself challenged, if not undermined, by the tenacity of local cultural schemas.
Under this condition, the state finds itself compelled to develop ways and means to

pursue its agenda of subjugating what it has constructed as "traditional beliefs and

 

practices” of recalcitrant malaria-ridden rural populations. From the point of view of

the state, health education, which is based largely on the knowledge claims of
biomedicine and biomedical sciences, constitutes a powerful weapon to achieve
people’s participation. This strategy suffers from, what I would call, the ”fallacy of
the undiscerning mind" attributed to ”traditional rural societies.” In this connection,
Grammicia’s observations are instructive:

Malaria is part of a socioeconomic depression complex from which
people have difficulty singling out malaria for particular concern.
People in malarious areas have for centuries regarded malaria as part of
their everyday lives; they have been conditioned to live with it and with
other scourges, such as poverty, hunger in certain seasons, and other
diseases. The people cannot understand why malaria should be selected
for elimination rather than poverty, hunger, or other diseases or
conditions.... The multiplicity of afflictions the people suffer takes
away a good part of their motivation they might have for self-help in
controlling malaria. [1981:386]

In my examination of the antimalarial program in the Philippines, I also paid
heed to the call for transcending a strictly localized view of social dynamics by

implicating the role of larger socioeconomic and political forces. I have endeavored

157
to explicate the historical roots of the malaria control program, in which I
underscored the political and economic goals underlying the establishment of public
health programs. The health condition of the rural work force was and still is a
paramount concern in the ”U.S.-supervised Philippine economy” (Neher 1991:75). In
addition, I have noted the support given by international agencies towards the
realization of these goals.

The malaria control program illuminates the patron-client relationship that has
been forged between the Philippines and foreign aid agencies responsible for setting
up the public health system in the Philippines. The antimalarial program is part and
parcel of the global health agenda set by international health agencies, whose work
historically included the following assumptions:

(1) that wealthier countries have the capital, the talent, and the "know-

how" to solve the health problems of poorer countries; (2) that the

wealthier countries should therefore plan and direct such efforts; and

(3) that Western health institutions and approaches will work in solving

health problems in LDCs [less developed countries].... [Rubenstein and

Lane 1990:367]

Increasingly, medical anthropologists and social scientists alike have begun
calling attention to the politics of international health and have come up with critiques
of the cultural assumptions that underlie its modus operandi (e. g., Crandon 1983;
Justice 1986, 1987; Morgan 1989; Taussig 1978). My inquiry speaks to that concern.
The medico-technological bias of the Western health enterprise has been central to the
conceptualization, financing, and implementation of antimalarial efforts of the global

malaria control program. As indicated in Chapter Three, the Philippine state has

always subscribed to the policies and strategies of WHO, which, together with

158

USAID and other international private foundations, has been providing technical and
financial support for the antimalarial campaign in the country. What this suggests is
that the Philippine state as a ”less developed country" has to contend continually with
its position in the global political economy.

The analysis of antimalarial control in Masipi developed here reflects the
interplay of the structures of domination (i.e., the authoritative knowledge of science
and biomedicine, the barangay structure, top-down health planning and
implementation, and international health and development schemes) with the
socioculturally constructed modes of thought and action of the Ilokanos in Masipi. It
represents a case for an understanding of the processes responsible for the constraints
faced by a state-led disease control intervention, constraints that are shaped by the
dynamics between an ethnomedical system that is rooted in local experience and a
disease control schema that is grounded in biomedicine and the logic of economic
development.

As a final remark, my analysis of the antimalarial campaign among the
Ilokanos of Masipi eschewed an analytic framework of ”traditional medical system
versus modern medical system," a framework that tends to view culture as a
conservative force. I analyzed local apathy, ambivalence, and resistance towards the
antimalarial program in terms of the concept of cultural politics to call attention to the
dynamics of power and meaning taking place in the interactions of the Ilokanos with
the state-supported health functionaries. Rejecting the tendency to view culture as
static, my analysis highlighted the ways in which the Ilokanos have reconfigured the

antimalarial program in terms of their own cultural schema. Thus, apathy,

 

159

ambivalence, and resistance represent the Ilokanos’ responses to the state’s
antimalarial program that gives primacy to "mosquito control,” an orientation that

tends to overlook the complexities of the cultural experience of the Ilokanos.

APPENDIX

160
APPENDIX

Presidential Decree No. 70

INSURING THE SUCCESSFUL OPERATION OF MALARIA ERADICATION
CAMPAIGNS IN THE PHILIPPINES

WHEREAS, there were pending before Congress prior to the promulgation of
Proclamation No. 1081 dated September 21, 1972, certain measures vital to the health
and economic conditions of the people; and

WHEREAS, one of these measures is a bill entitled ”An Act Insuring the
Successful Operation of the Malaria Eradication Campaigns in the Philippines;" and

WHEREAS, this measure will greatly help in reducing to the minimum the
incidence of malaria, if not totally eradicate it, thereby removing one of the deterrents
to our economic endeavor;

NOW, THEREFORE, I, FERDINAND E. MARCOS, President of the
Philippines, by virtue of the powers vested in me by the Constitution as Commander-
in-Chief of all the Armed Forces of the Philippines, and pursuant to Proclamation No.
1081 dated September 21, 1972, and General Order No. 1 dated September 22, 1972,
as amended, and in order to overcome serious setbacks in malaria eradication
campaigns on account of the refusal of houseowners to cooperate in this campaign, do
hereby decree that H. No. 15077, entitled ”An Act Insuring the Successful Operation
of Malaria Eradication Campaigns in the Philippines," as herein incorporated, is
hereby adopted and approved, and made part of the law of the land.

SECTION 1. To insure a successful campaign for the eradication of malaria
in the Philippines in order to promote the general health and welfare of the people as
a whole and to alleviate specifically the injurious effects of malaria on agricultural
productivity, rural development, industrial endeavor and community development,
anti-malaria workers of the Malaria Eradication Service of the Department of Health
are hereby authorized:

(a) To enter private premises, dwellings and yards without being guilty of
trespass thereof, in order to spray the houses or to canvass for malaria cases, take
blood films, give treatment and other anti-malaria activities necessary to eradicate
malaria;

(b) To gather data from other agencies for consolidation of records on the
incidence of malaria and to conduct investigation, studies, research and demonstration
with the view of discovering a solution to the problems incidental to the purpose of

161

this Decree.

SECTION 2. Government and private hospitals, clinics and other health
agencies are required to report to the Malaria Eradication Service in the Department
of Health any incidence that may come to their knowledge.

SECTION 3. Anti-malaria workers shall see to it that the insecticide residue
on sprayed surfaces, being essential to the success of the anti-malaria program, shall
not be willfully removed but must be allowed to stay on the wall until the termination
of the spraying campaign.

SECTION 4. Any person who refuses or obstructs an anti-malaria worker
from the performance of the duties provided in this Decree or refuses, without just
cause, to allow said worker free entry to his premises during a malaria control
campaign shall be fined not less than three hundred pesos nor more than five hundred
pesos, or by imprisonment for not less than one month but not more than three
months, or both, depending upon the discretion of the court.

SECTION 5 . The Director of the Malaria Eradication Service, with the
approval of the Secretary of the Department of the Health, is hereby authorized to
issue rules and regulations for the proper implementation of the other provisions of
this Decree.

SECTION 6. All Acts, parts of Acts and executive orders inconsistent with
the provisions of this Decree are hereby repealed.

SECTION 7. This Decree shall take effect immediately.

Done in the City of Manila, this 27th day of November in the year of Our
Lord, nineteen hundred and seventy-two.

By the President:

(Sgd.) ALEJANDRO MELCHOR
Executive Secretary

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