• I want my MDGs
• Whither the MDGs?
• Toilet trouble
• An island slakes its thirst
• Naga City’s class act
• A school board makeover
• Making sure Mama makes it
• No cure for costly medicines?
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• Arroyo fails COA audit: Fairness of President’s books ‘doubtful’
• Gloria’s spending spree: Travel, ‘donations’ top Palace expenses
• First Person
  Still reeling from military junta, Burma a mess after cyclone
• Perspective
  An absolute privilege

VALLEHERMOSO, CARMEN, BOHOL — Had she been in the same situation eight years ago, Jesusa Panes would have probably just given birth at home, even without her husband in sight, and even if her neighbor the hilot (traditional birthing attendant) happened to be drunk. But things have not been the same for expectant mothers in this town since 2002, and so when the child in her belly starting demanding to be let out, Panes began trudging toward the birthing center that was several minutes away by foot from her home.

The drunken hilot did his duty by swaggering behind her, seeing to it that she got to the center safely. Carmen is in fact the only town in Bohol that has legislated that all mothers must give birth at designated birthing facilities in five barangays or at the town’s birthing center (rural health unit or RHU), a P2.5-million, sprawling facility that offers first-class service for very low fees. Carmen’s laws also say a hilot should bring laboring mothers to the nearest birthing clinic to ensure a comfortable and safe delivery. And even if a hilot is trained, he or she cannot aid in a delivery, unless a midwife sits nearby to oversee the process.

	THESE days, mothers like Lilia Angcog can give birth for only P500. [photo by Avie Olarte]

The result of such legislation has been practically no maternal death in Carmen’s 29 barangays in the last five years, save for one in 2006. According to Dr. Josephine Jabonillo, Carmen’s municipal health officer (MHO), that unfortunate mother-to-be tried to deliver at home, with her father-in-law as the hilot. The father-in-law turned out to be untrained; the woman hemorrhaged to death.

“Most maternal deaths can be prevented,” says Jabonillo, an obstetrician/gynecologist. “Mothers all over the world die due to the same major complications of pregnancy: hemorrhage, hypertension, sepsis, and unsafe abortion.”

Globally, women continue to die due to complications of pregnancy and childbirth at a rate of one per minute. The limited progress in making motherhood safer is more alarming in developing countries, where 99 percent of maternal deaths occur every year. Here in the Philippines, about 10 to 12 women die every day due to pregnancy-related causes. The government has even admitted that it may not meet its commitment to achieve Millennium Development Goal (MDG) Number 5 — to drastically reduce the number of maternal deaths — by 2015.

And yet here is this town of 41,519 people that has been demonstrating just how far better local governments can be at keeping mothers healthy. Aside from its innovative laws regarding maternal health, Carmen also has what it calls the Enhanced Safe Motherhood Program (E-SM), which not only pushes for a RHU-based delivery, but also includes a pre-natal assessment, monthly check-ups, access to medicines, and other maternal health services — all for a nominal fee.

Location map of Carmen, Bohol courtesy of Wikipedia

TO FULLY appreciate what Carmen has accomplished so far, consider this: as late as 2005, the proportion of births attended by skilled health workers nationwide stood at 63.7 percent. In 2006, meanwhile, the national maternal mortality rate — the number of deaths per 100,000 live births — was 162. To be considered as having met MDG No. 5, the Philippines has to have all births attended by skilled health workers by 2015, as well as have reduced the maternal mortality rate to 52.3.

This predominantly agricultural town with more than half of its people living under the poverty line has managed to best those numbers — and how.

Yet even up close, there seems to be nothing that can make Carmen stand out among other rural towns across the Philippines. There are the small town center that passes for its urban area and a collection of dusty barangays. There are some cars and jeepneys and a lot of motorcycles. And just like any other Philippine town, there are children — lots of them — scampering about in the streets.

Then again, there is that birthing center, a 10-bedroom facility that is complete with delivery tables and laboratory equipment and can top the services of any hospital in this province some 800 kms south of Manila. Completed in 2006, it won a Sentrong Sigla Award (Center for Vitality) the very next year. According to the Department of Health (DOH), it is one the best rural health units in the country.

Building a good facility was on top of Jabonillo’s list when she became the town’s health officer in 2002. But she says it was no easy task, recalling that she had to first lobby hard with the local government officials.

“Carmen at the time had a very high record of maternal death,” Jabonillo recounts, “So I told the mayor we had to address it.”

Although the E-SM was Jabonillo’s idea, the local health board (headed by the mayor, and with Jabonillo, a councilor, and a nongovernmental organization representative as members) helped craft the program.

For the past five years, Carmen has had no maternal deaths except for one in 2006. Credit that to its award-winning rural health unit, which is complete with bedrooms, delivery tables, and laboratory facilities. [photo by Avie Olarte]

Jabonillo says that the town records revealed that the maternal deaths in Carmen were often caused by unhygienic and improper birth delivery practices. She also noted that there were also few skilled birth attendants, while women barely had access to pre-assessed normal delivery from the provincial hospitals.

These days, aside from the main one in the town center, five of Carmen’s barangays have birthing facilities. There are no doctors in these centers, but a midwife is usually on call, along with an army of barangay health workers; should any complications arise, an ambulance (Carmen has six) can be dispatched to bring the pregnant woman to the RHU.

But convincing the women to try the services of these clinics proved difficult. For one, the women thought they would be charged high rates. For another, they were simply more used to the hilot, some of whom even discouraged the pregnant women from going to the RHU. (This is, after all, a country where half of births still occur at home, and a third assisted by hilots. In Bohol, 17 percent of all the births in 2006 were aided by trained and untrained hilots, most or 53 percent are assisted by midwives.)

On E-SM’s first year, the RHU had a total of only eight deliveries. But by 2006, which was also the year the council passed the ordinance banning trained hilot from delivering babies, about 400 women ended up giving birth in the town facility.

“Maternal and birth complications were reduced to 50 percent,” Jabonillo says, leading to Carmen’s near-zero maternal death record.

AT VALLEHERMOSO, one of the barangays with a birthing center, the barangay midwife keeps track of all the pregnancies in the area. The health unit has on its white wall a pregnancy watch board that lists the names of pregnant women, together with the estimated date of confinement, last menstrual period, place and (estimated) date of delivery. There are also free pre-natal check-ups and some medicines, like iron tablets (many of Carmen’s women are anemic), are free as well.

Lilia Ancog’s barangay has no birthing center yet, so when time came for her to deliver her third child, she went to the main birthing center in town. Even then, she says her total bill came to only P500, or about 25 percent of the cost of a hospital-based delivery. She says that with her two older children, she had paid double that amount, and those deliveries were even done at home through a midwife.

“(It’s) high quality obstetric services at very reasonable amount,” says Jabonillo, who does not charge a doctor’s fee for the deliveries she does.

The doctor says that all the birthing center’s proceeds go to buying medicine and supplies like gloves and cotton, on top of the P1-million worth of drugs that the local government allocates for the RHU every year.

A patient in Carmen can even end up not paying anything at all. Last September, Carmen came up with a program for indigents with the government-run Philippine Health Insurance Corp. Through the program, a patient can avail of the Maternity Care Package that covers the first three deliveries, newborn screening, laboratory works, accommodation, medicine, and the P500 user’s fee.

VALLEHERMOSO remains one of the most densely populated barangays in Carmen. More than half of its population live below the poverty line. [photo by Avie Olarte]

That’s not all: Carmen is also one of only three towns in Bohol that have adopted a Reproductive Health Care Code; Bohol province itself has yet to pass one.

Carmen’s code mandates, among others, that women must have access to safe and quality reproductive healthcare services and that there should be a continuous planning, implementation, and monitoring of effective reproductive-health programs.

The code also ensures a steady stream of funding for reproductive health services, on top of the P50,000 allocated for the reproductive health advocacy program. A look at the town’s spending pattern shows that it allots an average of nine percent every year for health services compared to an average of four percent for infrastructure. (In most towns in Bohol, as in many local governments, building roads and bridges is prioritized over health and social services.)

For sure, though, the code has its critics. Some church workers have called its proponents “devils” and even launched a radio program to discredit the local officials pushing for it. One official who suffered such a backlash is Nathaniel Binlod, a two-term town councilor and chairperson of the town’s health committee. He almost lost in the 2007 elections, he says, for openly advocating and raising awareness on reproductive health and population management.

“I’m not for abortion,” says Binlod, who was born and raised in Carmen. “What I’m campaigning for is responsible parenthood. Two to three children are enough.” (The average family size in Carmen at present is 5.3.)

ACCESS TO reproductive-health services in Carmen comes in the form of making contraceptives available to the public. Together with the United Nations Population Fund (UNFPA) — with which it has partnered for such things as the ambulances and setting up barangay birthing centers — the town has built a Pop Shop that sells condom and pills at lower prices than those at retail stores.

HEALTH workers keep track of the condition of pregnant women in Vallehermoso. [photo by Avie Olarte]

The RHU itself allots P50,000 to P75,000 a year for buying contraceptives alone. The award-winning facility even has a Family Planning Room where couples can consult with a doctor regarding which family planning method would be best for them.

More Pop Shops are already being put up in the barangays. But women like Beatriz Manda, a 44-year-old mother from Vallehermoso, are unlikely to step foot into one unless they visit a local health unit first.

Manda says the natural way doesn’t work for her and her husband, because she has irregular periods. They already have 11 children, with the youngest only five months old.

But it may take some doing before she and her husband consider artificial family planning methods. “I’m afraid of the IUD (intrauterine device),” says Manda. “My husband meanwhile doesn’t like the condom, he says it might slip off.”

Someone also told her that once she has had a ligation, she wouldn’t be able to help her husband in the farm anymore.

Manda confesses that she has not paid a visit to the barangay’s midwife, who could help clarify common misconceptions on artificial family planning methods. But she says she is planning to go one of these days.

CONDOMS and birth-control pills can be bought for a cheaper price at Popshops. [photo by Avie Olarte]

If she opts to go to the RHU, she may just bump into Lilia Ancog, the mother who just gave birth there. Ancog is planning to visit the town doctor again as soon as she has had a few days of rest. She says she and her husband need a family-planning method aside from the natural way, which doesn’t seem to work for them. Her husband wants a fourth child, but Ancog says they can afford only three.

As for Jesusa Panes — the pregnant woman who with her drunken hilot walked all the way from her home to the barangay health center — she reached the place in one piece, the baby still safe in her tummy. And while she was sweating profusely when she arrived and was visibly worried that she would give birth any minute, she seemed to calm down somewhat after she downed a glass of spring water. As people fanned her, Panes politely declined offers to bring her to the nearest hospital, saying the midwife would take good care of her.

She later gave birth to a baby girl, her fourth child. Mother and newborn daughter are doing fine.

Inviting a man as guest speaker posed a problem to the group, which had a long tradition of keeping its activities exclusive to women. But it was decided that Senator Raul Roco was it, and he was named an “honorary woman” so he could grace the group’s anniversary celebration.

Indeed, women have much to thank the late lawmaker for his pioneering pro-women legislation, including the Women in Development and Nation-Building Act, the Anti-Sexual Harassment Law, the Anti-Rape Law, and the Child and Family Courts Act. But even back then, many wondered why the Soroptimists wound up with a man for their guest speaker. Were there no female legislators with the same qualifications?

Roco was a former congressman; he would also serve three terms as senator. During his years as a lawmaker — from 1987 to 2000 — a total of 106 legislative posts were held by women: 14 seats in the Upper House and 92 in the Lower House. Today 50 of the 238-member House of Representatives are women (21 percent of the total House membership), the most number of female legislators in the post-Marcos era. One of the five deputy speakers of the House is also a woman. Yet more than a decade after they picked a man to be their guest of honor, the Soroptimists may still be hard-pressed in inviting a female legislator who is as identified with women’s issues as Roco was.

Party-list representative Ana Theresia Hontiveros-Baraquel of the Akbayan Citizens’ Action Party says there is a potential women’s vote in Congress that could be harnessed into a solid bloc to push for pro-women laws. But Hontiveros-Baraquel, who women’s groups say is one of the easiest to invite to their activities, is the first to admit: “The fact that the lawmaker is biologically female does not automatically mean she would have a feminist perspective. It is not biologically deterministic that way.”

In fact, of the more than a dozen laws passed between the Eighth and 12th Congresses that women’s groups consider as important to their causes, at least seven garnered a higher percentage of support from male legislators than the female lawmakers. (see Table 1) Just one of the three women members of the Lower House who are now on their fifth term can claim to have championed a pioneering pro-women law. Republic Act 7600, which provides incentives to health institutions with rooming-in and breastfeeding practices, also had no female among its authors and sponsors.

FOR SURE, the Philippine legislative landscape has seen some major improvements with respect to women’s rights in the last two decades, and the environment seems to have changed a lot for women. Women’s rights activist and newspaper columnist Rina Jimenez-David even says that when she was out campaigning for the party-list group Abanse! Pinay in the last elections, “a woman professor asked me if there was really still a need for a women’s party list since there are laws covering almost all women’s issues.”

Obviously, Jimenez-David and other women’s rights advocates believe there are still important pieces of legislation regarding women’s welfare that need to be passed. Carolyn Sobritchea, executive director of the University of the Philippines Center for Women’s Studies (UPCWS), cites as an example the stalled Reproductive Health Care bill, which she says recognizes the rights of women over their bodies. She also says that although legal separation and the annulment of marriage are now allowed under the Family Code, many women would like a law that could provide more protection and security for single mothers and their children. There is a need as well to look into the rights of women in the agricultural and informal sector, she says.

“We’re happy and we’re not happy,” says Sobritchea. “We have passed 16 groundbreaking laws on women, (among) the most progressive in the world. But we still have our work cut out for us.”

What some find curious, however, is that even previous “pro-women” laws got their boost not from female legislators, but from the males. For instance, it was in the Eighth Congress where so far the most laws addressing women’s concerns were passed in the post-Marcos era, among them Republic Act 6955 (which sought to make illegal matchmaking local women to foreign nationals by mail-order). RA 6955 even saw only 26 percent of the women representatives voting for it, compared to about 55 percent of the men.

At the time, there were only 19 female lawmakers in the Lower House, or a mere nine percent of the representatives — the lowest so far in the post-Marcos era. (see Table 2) Indications are these female legislators were reluctant to be too identified with women’s causes. Jimenez-David recalls, “Many of them first-timers, they confessed to feeling they had to first ‘earn their spurs’ as representatives of a general constituency, and that championing women’s issues might limit their influence and appeal.”

“But that was in the past,” she says. “(Women) in both (Houses) have in the years since been able to pass women-friendly laws and turn the legislature into women-friendly environments.”

Hontiveros-Baraquel, though, says that even today only the party-list organizations Abanse! Pinay and Gabriela Women’s Party could be counted on as a solid vote for pro-women legislation — leaving out her own organization, which supports the implementation of the 30-percent quota for women in all decision-making bodies. Hontiveros-Baraquel herself actively supported the anti-prostitution bill in the last Congress, as well as House Bill 5496, which aims to strengthen women’s participation and representation in elective and appointive positions. Yet she is more well-known for her human-rights advocacies.

Even Senator Loren Legarda, whose platform includes women’s causes, is not that identified with women’s concerns. This is even though she co-authored and sponsored the Anti-Violence Against Women and Their Children Act of 2004 (RA 9262) — the consolidated version of the Anti-Abuse of Women in Intimate Relations bill and the Anti-Domestic Violence bill — and the Anti-Trafficking in Persons Act, which was passed into law as RA 9208.

“Generally, the members of the Senate vote based on issues, which does not necessarily have any relation with gender,” comments Legarda. “But I believe that there is a women’s vote when the issue to be resolved is on women’s rights and welfare.”

THERE HAS been, however, at least one female legislator outside of party-list groups with women’s rights advocacies who was very vocal about her pro-women stance: Leticia Ramos Shahani. She and Santanina Rasul became the first female senators in the post-Marcos Congress. Says Shahani: “Once elected, I asked myself, for whom do I legislate and what do I legislate? I had no doubt that I had to legislate for women because I correctly felt that I represented them.”

She does clarify that “a senator cannot just be a class legislator,” and that she was not just “a senator for women.” She stresses, however, that she never forgot that women’s issues were her priority.

In fact, the first bill that Shahani authored and that was made into law was RA 6725, which sought to strengthen the prohibition on discrimination against women in the workplace. She is also proud of having introduced during the debate on the national budget in 1994 the mandatory allocation of five percent of the budget of every government department and agency for gender and development. But she considers the two laws on rape — RA 8353, which redefined the crime, and RA 8505, which provides assistance to rape victims and their families — as the centerpieces of her “feminist legislation.”

Rasul, meanwhile, seemed to have been also busy with women’s issues in the Upper House. Once the chair of the Committee on Women and Family Relations in the Senate, she co-authored the Women in Development and Nation-Building Act of 1995 (RA 7192) with Senator Roco. The Act outlawed discrimination against women, opened the doors of the Philippine Military Academy to women, and mandated that a substantial portion of government funds at all levels be used for programs that would benefit and develop women’s capabilities.

Rasul also sponsored RA 6949, which declared March 8 of every year as National Women’s Day, a special working holiday, as well as RA 6955. And she is credited for having provided funds for the UPCWS building, seeking the help of her fellow senators when the center’s coffers were nearly empty.

Congress observers say few women in the Lower House seem to have matched Shahani and Rasul’s pro-women legislative efforts. One of the exceptions, they say, was Bellaflor Angara-Castillo, who was the representative of the lone district of Aurora from the 10th to the 12th Congresses. Angara-Castillo, now Aurora’s governor, was a strong advocate not only of women’s rights, but also that of gays and lesbians during her stint in Congress.

Observers agree with women’s-issues activists that female representatives oftentimes choose to be “silent” because of their lack of skills to defend bills on the floor. UPCWS’s Sobritchea also points out that women elected to Congress have “different profiles, from the most conservative to the most progressive,” and therefore will not necessarily act as one, even when it comes to laws considered by many to be in support of women’s rights.

Sobritchea remarks as well that many of today’s female legislators are “conservative.” She says that some, for instance, still believe that “no matter what has been done — you die, you are poisoned inside the house — marriage is inviolable and men and women should suffer in a very unhappy marriage.”

IN TRUTH, several female legislators ended up in their seats primarily because they belong to political families, and not because they were seen as potential supporters of women’s causes. In the current Congress, 20 of the female representatives (or 40 percent of the women legislators) directly inherited a parent/-in-law’s slot (three) or are replacements of husbands (14) or brothers (three). (see Tables 3, 4, and 5)

Then there are Representatives Thelma Almario of the 2nd district of Davao Oriental who had served successively in the Eighth, Ninth, and 10th Congresses, and was replaced by her son Mayo Almario, who served in the 11th, 12th, and 13th Congresses; and Carmencita Reyes of the lone district of Marinduque who had served in the Eighth, Ninth, and 10th Congresses, and was promptly replaced by her son Edmundo Reyes Jr. in the 11th, 12th, and 13th Congresses. Both Almario and Reyes have now replaced their sons, who had reached their term limits. Representative Carmen Cari of the 5th district of Leyte, meanwhile, replaced her niece Representative Ma. Catalina Loreto-Go, who served in the 11th Congress.

The newest deputy speaker of the House, Occidental Mindoro Representative Amelita Villarosa, herself took the seat vacated by her husband Jose several years ago. But when she was named deputy speaker, no less than Speaker Jose De Venecia said that Villarosa was chosen “to address the gender imbalance in the House, so that women legislators will be represented in the House leadership.” Villarosa, though, has since taken pains to explain that “I was elected as a deputy speaker, period, not a deputy speaker for women. There is no such position in the House.”

“The job of the deputy speaker is to help the speaker carry out the functions of his office,” she adds. “I am deputy speaker for everyone, not just for a particular sector.”

At the very least, Villarosa is not known for women’s causes. Of the 57 house bills she filed during her previous term, only one could be described as being pro-women: House Bill 4948, which seeks to expand the grounds for legal separation and to amend the definition of psychological incapacity under the Family Code.

IT’S A performance that she shares with other veteran female legislators, including those who have been in Congress for far longer than the rest. Three current congresswomen are now on their fifth term: Representative Belma Cabilao (who has served both in the 1st and 3rd districts of Zamboanga Sibugay), Representative Glenda Ecleo (who is currently serving in the newly-created lone district of Dinagat Islands and has previously served in Surigao del Norte, 1st district), and Representative Nerissa Corazon Soon-Ruiz (Cebu, 6th district).

Of the three, only Ecleo can boast of having championed a pioneering pro-women legislation: the Anti-Rape Law of 1997, which she introduced in the Ninth Congress as the chairperson of the Committee on Women. Although her term expired without the bill getting passed, she, through the lobbying efforts of women’s groups, had more or less laid the groundwork for the bill’s enactment in the 10th Congress.

Soon-Ruiz, meanwhile, co-authored the proposed Reproductive Health Care Act (House Bill 4110) in the 12th Congress. But she later withdrew her signature following pressure from the Roman Catholic Church — specifically from Cebu Archbishop Ricardo Cardinal Vidal, who was reported to have said he would not vote for Soon-Ruiz and would actively campaign against her in the 2004 polls if she did not do so. Soon after the opening of the 14th Congress, one newspaper quoted the lady lawmaker from Cebu as having assured Vidal that reproductive health care bills would not pass in the present Congress.

That may put her up against Villarosa who, despite her reluctance to turn her election as deputy speaker into a gender issue, promises nevertheless that she will give special attention to women. Villarosa says she co-authors two major pieces of legislation on women in the current Congress, one of them being the Reproductive Health Care bill. The other is the Magna Carta for Women, which would “operationalize” the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), an international women’s rights treaty to which the Philippines is signatory.

This early, Villarosa sees trouble ahead for the Reproductive Health Care bill, and this time around, the heel-digging may be evenly distributed between genders. She says that when she and other legislators tried to discuss the bill recently, “the guys stood up and said it was not yet time to talk about it.”

Villarosa’s new position as deputy speaker, however, means that women’s rights advocates expect her to fight for the bill with all her muster — and then some. Hontiveros-Baraquel even poses the challenge to the House leadership: “Villarosa’s election is a victory for women in the sense that it created gender balance. But it is yet to become a fully realizable victory (until) Representative Villarosa (lends) her position and influence to advance women’s causes.”

Senator Legarda agrees. “Women legislators have to support women-related legislation,” she says. “Women comprise half of our population, and while women in our country are considered better off than (women in other cultures) in terms of rights and welfare, there is much to be desired in terms of women’s participation in governance and decision-making. So those who have the opportunity to speak up for other women because of the positions and posts that they hold must do so with zeal and dedication.”

SANITARY napkins line the shelves of supermarkets. [photo by Isa Lorenzo]

Environmental groups like Bangon Kalikasan Movement (BKM) say the mountains of trash in dumpsites like Payatas in Quezon City contain a very hefty share of soiled baby diapers and used sanitary napkins. The trash in Payatas has piled up to a towering 50 feet, equivalent to five stories. Seven years ago, a thousand people were killed when the trash came tumbling down on scavengers and those living in huts near the steaming mounds of garbage.

BKM convenor Annette Papa believes that the first environment is the person, and that people need to take care of themselves so that they can take care of the environment outside their personal space. Yet while women are usually active participants in green movements, few of them seem to realize that a product they buy month after month isn’t eco-friendly at all.

It’s bad enough that the disposable sanitary pad is for single use, which means more pressure on resources that are vital to its manufacture, aside from more waste headed for the dumpsite. The cover of the modern sanitary napkin, whether net-like or nonwoven, is also made of plastic, as are the bottom layers. Most napkins these days are packed individually in plastic, too, and then sold in multiples, which are, yes, in plastic packs. Plastic is nonbiodegradable. In dumpsites, says Papa, it contributes to toxic emissions, especially when mixed with heavy metals like lead, cadmium, and mercury. These emissions, which are mostly dioxins and furans, are carcinogenic, and can also cause tuberculosis and other respiratory diseases.

Mixed garbage produces methane gas as well, which Papa says contributes to global warming. In addition, plastic trash often clogs canals and waterways, thereby contributing to floods.

Its plastic components and no-fuss application are what make the modern sanitary napkin so convenient for today’s multi-tasking woman. But women’s studies professor Dr. Sylvia Estrada-Claudio says that once she became aware each time she threw away a sanitary napkin, she was generating nonrecyclable trash, she ceased to see disposable sanitary napkins as “convenient.”

Environmental lawyer Ipat Luna also points out that it isn’t only the plastic in disposable sanitary napkins that’s harmful to the environment. “All the energy that would go into production, not just the pad itself, but the plastic, the waste material from the production process, the delivery — it’s a very wasteful cycle altogether,” she says. “And it’s unnecessary. And when there is something to replace something that is unnecessary and that replacement is easy, it’s a no-brainer.”

THE MOST common “replacement” for the disposable sanitary napkin, of course, is the pasador, or those folded pieces of cloth that women a generation or two ago used whenever they had their monthlies. Luna says she began using a commercial version of the pasador — ordering a set of washable, 100-percent cotton napkins from the Internet – when she started to become irritated over the fact that she needed to throw away her sanitary pads. Six and half years later, her washable napkins are still in service.

Environmentalist Ipat Luna shows off her reusable sanitary pad. [photo by Isa Lorenzo]

“I hardly throw anything out, so ‘pag ganyan na araw-araw may tinatapon ka, nakakasama ng loob eh (when there’s something you have to throw out every day, you feel bad),” she explains. “And then you know that other people are grossed out by what you throw away, you have to wrap it up. It just wasn’t jibing with the rest of my lifestyle.”

Besides, she says, it wasn’t as if she was satisfied with her disposables. “There are environmental choices where it’s harder to make compromises on, but this one for me was easy, because to begin with, the product is horrible to me,” says Luna. “(Disposable sanitary napkins are) just badly designed — they bunched up, they leaked, they scratched. And even this wings thing, they don’t help. They don’t conform to the contour of your private parts, so they just don’t work.”

Gynecologist Dr. Elsie Dancel herself says the fibers in disposable sanitary napkins can cause itchiness and irritation for women who have hypersensitive vulvar skin. Thirty to 40 percent of her patients, she says, complain of irritation due to sanitary pads. A few have gotten urinary tract infections (UTIs) that Dancel believes may have been caused by pressure elicited on the urethra as a result of using sanitary napkins. Other health experts, meanwhile, worry that the scents and gels in some pads — plus the chlorine bleach used to whiten the napkins and enhance their appearance — can cause skin irritations, among other things.

Dancel, 58, grew up in Cagayan de Oro. She says she used a pasador until she graduated from high school. She never felt any itchiness or irritation when she was using cloth napkins, which were secured in place with safety pins, says Dancel. When she came to Manila, however, the convenience of using disposable sanitary pads proved too difficult to resist. After all, using a pasador means having to wash a blood-soaked piece of cloth again and again. And while the pasador is arguably kinder to the skin compared to its disposable cousin, it is prone to leaks. Dancel doubts that her own daughters would switch to reusable napkins. “They don’t want to see the blood and everything,” she says. All of her patients use disposable sanitary napkins.

Luna’s diva cup up close. [photo by Isa Lorenzo]

FOR SURE, a disposable product means its manufacturers are guaranteed to have their cash registers regularly going ka-ching. Last year, the global sales of the women’s health franchise of Johnson & Johnson, maker of the popular Modess brand, grew by 6.3 percent to $1.7 billion, partly because of the solid sales of one of the company’s sanitary napkin brands. Other multinationals such as Procter & Gamble and Kimberly-Clark are also behind local market favorites Whisper and Kotex.

The sanitary-napkin market cannot be anything but lucrative. Better nutrition has resulted in the earlier arrival of menarche (a girl’s first menstruation) and the later onset of menopause, says Dancel. These days a girl could be menstruating as early as eight years old, she says, and some women continue to menstruate up until the age of 56. Assuming that the average woman would go through at least three eight-napkin packs per cycle, that means a total of some 14,000 sanitary pads for just one woman in the 50 or so years that she has a period every month.

The cheapest local brand costs around P19.50 per pack of eight. The most expensive brand can cost some P200 for a pack of 10. The last two decades has also seen a rise in the popularity of panty shields, which are essentially just shorter and thinner versions of sanitary napkins. A pack of 20 scented panty shields can leave a shopper about P41 poorer.

Some women’s issues advocates rue the fact that a generous share of those pesos goes to advertising that, they say, often portrays what is very much a natural part of a woman’s life as something to be embarrassed about. Luna says that in some cultures, menstruation is celebrated, citing an American Indian tribe in which a mother and daughter go for a run on the beach in celebration of the daughter’s menarche.

Then again, Luna admits that there really are societies in which menstruating women are considered unclean and are made to live separately from the rest of the community whenever they have their period. She offers the theory as well that colonizers imposed a taboo on sex, and the corresponding private parts of the body, hence the stigma often associated with menstruation and sanitary napkins.

In any case, academic Estrada-Claudio says modern Filipino society is apparently not that comfortable with menstruation. “The message that society’s giving you is that (the) very mark which ushers you into being a woman is also the very threshold that you’re suddenly becoming sinful, which also has something to do with being sexual,” she says. “You have this whole norm of sexuality, particularly women’s sexuality, women’s libido, and women’s bodies, being stigmatized as something unclean, something unholy, something unsacred, something difficult.”

FOR ALL Estrada-Claudio’s concerns about what her used napkins are doing to the environment, though, she still cannot bear to swear them off completely. So she has compromised — sort of.

GYNECOLOGIST Dr. Elsie Dancel [photo by Isa Lorenzo]

“I tear my napkins apart,” she says. “I take the cotton and put it in the nabubulok (biodegradable), wash the (plastic), which makes my maids think I’m extremely crazy, and I try to tell them they should do it, too.”

But she doesn’t think many women would be willing to do the same. “It’s pretty icky to tear it apart,” she concedes, “and you kind of in fact lose the convenience — because it’s so convenient to just wrap it up and throw it away, so it’s not convenient for me anymore. Because I have to tear it apart, it takes me longer.”

BKM’s Papa also resorted to this method to segregate her used sanitary napkins. “I would just wet the whole napkin,” she says. “It’s easier to tear the side, separate cotton from plastic.” She cleans the plastic while the bloodied cotton is turned into compost by adding cocodust and water. The plastic is pulverized with a simple shredder. It can then be used as a filling for hollow blocks, or as pillow stuffing.

Papa has also learned how to use the pasador. But Luna says there’s another alternative to the disposable napkin: a washable silicone cup.

“You insert it folded,” she says. “And then when it gets into the opening, it opens up and it makes up a vacuum.” Luna says that once there’s a vacuum, there’s no leak. She takes her cup out every half day, depending on how heavy her period is. But she says she still prefers to use washable sanitary pads at night, so that she can still feel the flow.

Inserting the cup is tricky, Luna confesses. “You have to twist it a little bit so that plok! It makes a sound like that,” she says. “When it does that, it hits you, it’s like rubber bouncing on your uterus a bit, so it hurts. Plok! You feel its suction. Also, it’s hard to pull out because the stem is quite small.”

Several companies actually make contraptions similar to the one used by Luna. Hers is being marketed under the brand “Diva Cup.” It comes with its own flowered pouch and a little silver pin, which is for proudly announcing that the wearer is using a washable cup. According to Luna, her cup has leaked only twice so far. She says she may have inserted it wrong or perhaps her period was too heavy. Most of the time, however, it has stayed where it is supposed to be. “So you could swim, go to the gym, do anything with the cup in there,” she says.

WINALITE International Inc., a Chinese company, has launched a brand of sanitary napkins containing anions, which claim to decrease bacteria and even eliminate dysmenorrhea. [photo by Isa Lorenzo]

One major problem with the menstrual cup, which has been around for decades, is its price. Luna bought hers for $34, which in these days of the supposedly stronger peso comes to almost P1,600. Even with a guarantee that it can be used for up to 10 years, perhaps only divas and diehard environmentalists would be willing to fork over that much for one. And in a country where the tampon has never made much of a headway, a cup that has to be inserted up one’s private parts may not be much of a hit.

Still, people like Luna and Papa wish that more women would at least become aware of the downside of the modern convenience called the disposable sanitary pad. Says Papa: “It would be really hard to ask other women to shift, but when they come to understand it is something they can do to help mitigate the global trend of global warming, maybe they can do it.” Or perhaps they can start pressuring the major feminine-hygiene product makers to go green.

De Leon says the country’s population policy began in the late ‘60s, when then President Ferdinand Marcos issued presidential decrees and letters of instruction creating Popcom and making population management an integral part of his economic programs. “He understood the gravity of the population problem, that any economic gains will be lost if there’s no family planning,” says de Leon.

In 1986, the country’s population program weakened under a very devout Catholic President Aquino. But she gave then Health Secretary Alfredo Bengzon enough room to maneuver by placing Popcom under the Department of Health (DOH). The DOH pushed family planning by including it in its maternal and child health programs.

Under the Ramos administration, the population program was included in its reproductive health programs. “He addressed the problem and gave it strong support,” says de Leon.

The Protestant Ramos also prodded local government officials to craft their own program, giving out awards to the most effective ones. And he tapped the colorful “Doctor to the Barrios” veteran Juan Flavier as his health secretary. Also a Protestant, Flavier often clashed with the Catholic Church. But he won the support of the masses by popularizing his department’s health campaigns by tapping advertisers for free advise. It helped, too, that Flavier, while small in height, was big on humor.

Ramos’s successor, Joseph Estrada, had two “tutors” in family planning who explained in layman’s terms the relationship of rapid population growth to economic growth: then National Economic and Development Authority Secretary General Felipe Medalla and Health Secretary Alberto Romualdez. Estrada once said he was lucky his parents did not practice family planning because he was the eighth of 10 children. He is also known to have sired several children by women other than his wife. But with the “tutoring” he received from his economic and health planners, Estrada saw the wisdom in managing population, once even quipping to an audience to “work harder and limit your libido.”

De Leon said those in the population management sector were at first optimistic that Arroyo, being an economist, understood the importance of population and development. “No amount of development matters without population management,” he says. “She has a Ph.D. in economics. It seems she is hiding what she knows.”

He blames this on Arroyo’s fear of and subservience to the Roman Catholic Church. “We have reliable information that she has told her cabinet members not to talk about reproductive health in front of her,” says de Leon.

Some of President Arroyo’s statements regarding family planning, meanwhile, include calling natural family planning as “internationally known, scientific, practical and 99-percent effective.” She said this in a speech marking National Women’s Day in 2003, during which she also said that the natural methods “are means of family planning acceptable to the Catholic Church, to which most Filipinos belong.”

“Kaya hindi kailangan maghiwalay ang simbahan at family planning (So there should be conflict between the Church and family planning),” she said.

In New York in September 2005, Arroyo told the United Nations General Assembly and world leaders who were there that she “expect(s) the United Nations to respect the deep Catholicism of the vast majority of the Filipino people.” She added that the U.N. fund for reproductive health that was being given to the Philippines “shall be dedicated to train married couples in a natural family planning technology, which the World Health Organization has found effective compared to artificial contraceptives.”

A few months later, however, WHO Asian Region Representative Jean-Marc Olive was quoted as saying, “the failure rate of natural family planning is much higher than other contraceptives.

DATU PAGLAS, MAGUINDANAO — Prayers echo from the minaret of a mosque through a vast banana plantation. Owned by a company called La Frutera, the 1,000-hectare land used to be a “killing field.” At the time, men in the area wound up either as members of secessionist groups or in the middle of a “rido” or clan war.

But since 1997, when La Frutera set up shop in this town, men have ditched their guns to help grow the Cavendish bananas the firm exports. Benefiting from the peace that has taken over the land, many of them now own houses, and most of those houses have TV sets. Those among the men who are married also practice family planning.

“Parang tao rin ang saging, pag masyadong marami, maliliit lang ang bunga (Bananas are like people, when there’s too much, the fruits are tiny),” says a farm supervisor, in explaining why they limit the number of “hands” in each plant.

La Frutera runs a family planning-education program for its 2,000 employees, 95 percent of whom are Muslim men. As a result, the community it calls home has become a pocket of hope in Maguindanao, which is one of the country’s poorest provinces and where many girls are still being married off at an early age and giving birth at home. In 2005, the United Nations Children’s Fund (UNICEF) placed the province’s maternal mortality rate at 300 per 100,000 births.

In Muslim Mindanao, family planning was endorsed by the Assembly of Darul Iftah (Religious Leaders Assembly) on November 23, 2003. The assembly produced a document that said, “Islam has encouraged its people to increase and populate the earth with the proviso that their quality should not be compromised.” Stressing the principle of non-coercion, responsible parenthood, and informed choice, the assembly adopted family planning as a method to birth spacing. It also endorsed all methods of contraception.

A WORKER pulls newly-harvested bananas to La Frutera’s processing area. [photo by Jaileen Jimeno]

Muslims make up five to nine percent of the Philippines’ population of about 88.7 million people, who are all covered by a Constitution that guarantees freedom of faith and the separation of church and state, among other things. But since 2002, Filipinos of all faiths have been subjected to a national family planning policy that pushes only natural methods — a policy that echoes the beliefs espoused by the Roman Catholic Church, which claims some 80 percent of the country’s population as its followers.

The government, of course, stresses that those who want to use artificial contraceptives are free to do so. Health Secretary Francisco Duque says, though, that it is up to local government units to procure such supplies for their constituents. Those who are short on funds “can go to the USAID (US Agency for International Development),” which, he says, has a supply that is “good up to the end of 2008.”

The USAID has been providing contraceptive supplies to the Philippines since the 1970s. But it has been scaling down its donation in recent years; by the end of next year, it will shut down the program completely. A recent study by the United Nations Population Fund (UNFPA) estimates that the country needs at least $2 million a year to fund its contraceptives requirement to plug the vacuum the USAID would leave behind.

Cash-strapped local governments

For sure, some local government officials, especially those in the poorest regions, know they need to provide their constituents a good range of family planning methods. But many of them apparently do not have enough resources. Dr. Junice Melgar, head of the nongovernmental organization (NGO) Linangan ng Kababaihan or Likhaan, says that in one forum, a provincial governor complained about the DOH’s lack of support in this arena. The DOH officials present, however, could only repeat Malacañang’s line of giving natural family planning a chance.

This, say observers, has been a tremendous setback for the poorest provinces mostly in the Autonomous Region in Muslim Mindanao, where the highest “unmet needs” in family planning have been recorded.

Mary Catherine Sumapal, who mans La Frutera’s health clinic, recalls that when Datu Paglas was a killing field, girls would usually be married off by the time they were 13. They would then proceed to have children almost every year. “It was common then to see ‘do-re-mi’ children,” she says.

But now Sumapal says that with the Muslim religious leaders’ edict and La Frutera’s family planning program, which was launched early this year, there is at least a bigger chance for their workers to have planned pregnancies. In fact, the program’s first year supply of contraceptives worth P200,000 is now in the pipeline.

Rose Sira, La Frutera’s personnel department head, says the family planning program will help ensure that each farm worker’s child has health coverage. The company’s health service covers a maximum number of four children per worker. Sira adds, “The workers know that if they just keep on having wives or children, and they get sick, they spend a lot of time away from work, and they lose income.”

In a sense, La Frutera itself is already the most effective family planning tool in the province. As more heads of the family and young people begin to have financial independence, many are reluctant to be weighed in by raising a big family; young people delay marriage in favor of an education and a career.

Nevertheless, Ustadz Abdulwahid Sumaoang still counsels farm workers on family planning, especially the men, who have grown accustomed to a culture of having more than two or three wives, with their number of children often unplanned. He often tells them, “If you are God-fearing, you will plan your family.”

A Muslim professor, Sumaoang has been La Frutera’s values consultant since 2003. He says that he often had to mediate in couples’ fights, mostly because the men did not secure their wives’ permission before getting a second or third wife, as stated in the Holy Qur’an. Some also strayed from the Islamic ideals of choosing “widows and orphans” as second or third wife. “They have forgotten that it is a responsibility, an effort to provide sustenance to a disadvantaged woman,” he says.

Sumaoang says that Muslims also place emphasis on natural family planning. But he says that since this method is not 100-percent foolproof, they have made artificial contraceptives available should couples have the need for it.

La Frutera clinic’s records show that two percent of its clients have chosen natural family planning. The rest rely on artificial methods.

This may well reflect the general attitude toward family planning nationwide. In a Pulse Asia survey conducted just before the May 14 polls, 92 percent of the respondents said it is important to control and plan one’s family. Nearly nine in 10 also said the government should allocate funds for family planning measures other than natural methods.

Ateneo drops population management course

But advocates of natural family planning have become stronger in recent years, having clinched seats in various levels in government since Gloria Macapagal Arroyo became president. Recently, their influence has been felt even in schools like the Ateneo de Manila University, which is run by the Jesuits, who are considered to be mavericks among the Catholic orders.

This year, the Ateneo would have offered an MBA in Health, with emphasis on strategic population research management. But pro-life and several similarly aligned groups protested, saying that “as a Catholic university, the Ateneo should not be receiving funding support from an organization that openly espouses abortion, population control, and reproductive health.” Ateneo has dropped the course.

NURSE May Catherine Sumapal (right) counsels La Frutera’s workers on family planning. [photo by Jaileen Jimeno]

Dr. Napoleon Juanillo, program director of Ateneo’s Leadership and Managerial Excellence in Health Systems, says that being a “transplant” from Cornell University, he was surprised at the level of discourse on the issue of population in the country. “It’s pushing us back to the medieval period,” he says. “It is an affront to science, on the rights of women.”

He says the course, which was to receive a $250,000 funding from the David and Lucile Packard Foundation, would have elevated the discourse on population management to a “more intelligent, scientific level.” Yet while he expresses disappointment over the scrapping of the course, Juanillo says he takes his hat off to the Catholic Church and pro-life groups like the Alliance for the Family Foundation Inc. (ALFI) for having “a good war tactic.”

ALFI wrote letters to Ateneo officials and demanded that the course be pulled out. Says Juanillo: “They merely did what they had to do, since it is part of their advocacy.”

He admits that the university was unprepared for the negative reaction to the course. In the end, he says, the university was left all alone carrying the flag. He says NGOs should have backed the school, adding, “This is a wake-up call to the RH (reproductive health) groups. They should fight and join the sphere. The NGOs did not do their job.”

That may be because they were busy trying to convince local and national officials to fund family planning measures other than the natural methods. As some NGO workers tell it, they would rather not have a repeat of what happened to Manila under Mayor Joselito ‘Lito’ Atienza, who ended a nine-year run in City Hall just recently and is now the environment secretary.

Atienza banned contraceptives in Manila from 2000 to May 2007. Women interviewed earlier this year by Likhaan, the Reproductive Health, Rights and Ethics Center for Studies and Training (ReproCen), and Center for Reproductive Rights told tales of financial, physical, and emotional difficulties when contraceptives totally disappeared from Manila’s health centers.

Some of the 67 women interviewed for the NGOs’ study said they wanted to have two to three children, but ended up with more than double their ideal number of offspring when contraceptives and ligation at government-funded facilities were banned. All of them belonged to the poorest bracket of society, where a P35 packet of pills is an unbearable monthly burden.

Women, doctors tell tales of woe

One 32-year-old mother of seven said she had wanted just three children. She wanted to be ligated after her fifth pregnancy. But the public hospital she went to would not perform the procedure, citing Atienza’s Executive Order 003, which was already in effect. In language, that EO pushed for natural family planning, but in practice, it worked against any artificial method.

Then there was a 36-year-old mother of eight who had dreamed of having only two children. She said that she was unable to get her regular supply of pills. She wanted to undergo tubal ligation after her fourth child, but the public hospital near her home no longer offered the service. By then, she said, her family’s daily meals were already consisting of just three sachets of coffee and a few pieces of pandesal for breakfast, rice and soy sauce for lunch, and bread for dinner.

Officials of the Dr. Jose Fabella Memorial Hospital also observed many high-risk cases among women patients, because of “anemia, too-frequent deliveries, very short spacing, and sometimes no spacing at all,” said the NGOs’ study.

An official at another government hospital told the NGO interviewers that the ban resulted in many unwanted pregnancies, prompting a greater “tendency to have an abortion.” One hospital director, in fact, said that abortion complications, including deaths, were “the second largest cause of admissions in his hospital, and a leading cause (of admission) in most hospitals.”

Other women interviewed post-Atienza told of marital spats, physical and verbal abuse, and being abandoned by their partner because of their refusal to have sex to avoid getting pregnant.

Government health workers agree with those from NGOs that Atienza’s EO 003 should be revoked. But they say that with the national government policy on family planning similar to Atienza’s, a legal victory is unlikely.

Big population an economic plus?

Indeed, Jose Sandejas, President Arroyo’s consultant on family matters, downplays the report by Likhaan and company. “There are studies by people who have an agenda to push,” he says, “so you really have to look at who funded it.”

He adds that there are groups in Manila’s slums promoting natural family planning “and they will be the ones to tell you most men are responsible, even in the slums.” He argues that the urban population growth will go down even without contraception. Urbanization, he says, will leave couples naturally wanting smaller families because of the higher cost of living, as compared to living in the provinces.

Sandejas, however, would rather focus on the positive effects of keeping the population growth robust even though 2006 figures show this may be causing a downtrend in major education indicators like elementary enrolment and survival rate in schools.

“Even if you are not able to educate them as well you would like,” he says, “in the end their capability to quickly learn skills in the health services, in construction, as seamen, is going to save the Philippines.” Sandejas says that even the current generation, “where we have low levels of education, our overseas Filipino workers are saving us at this time.”

It’s a line that could well upset people like medical anthropologist Michael L. Tan, who writes a popular column for the Philippine Daily Inquirer. In a 2003 column on Arroyo’s policies, he observed the president, being an economist, should know better than “arguing that a large population is good for the economy because it means more consumers, more business, even more workers to export.”

“There is just no way government or the private sector can cope with the demands for jobs, housing, health, education and other social services, not with the present rate of population growth,” Tan added. “As for exporting Filipinos as caregivers to the world, I find it terribly immoral that we can think of producing children mainly because we see them as possible exports to bring in dollars later, even as we export their parents today.”

Interestingly, Arroyo’s stance is nowhere near that of Ed Panlilio, a Catholic priest who is the new governor of the president’s home province, Pampanga. According to Panlilio, he will pursue the family planning program already in place at the capitol, and that includes providing artificial contraceptives to those who ask for it.

“As governor and a public official,” he says, “the reality is I cannot impose my Catholic stand on the issue. Otherwise, I will be violating the human rights of my constituents.”

Panlilio says he will ask health workers to offer the whole range of family planning options to couples so they can practice a method based on the dictates of their conscience. He admits this may make him a target of attacks by Catholic hardliners. But he says he is confident Church leaders will understand the position he has taken.

“Nobody should dictate the choices couples should take,” says Panlilio, “not even the Pope, not even the president.”

UBAY, BOHOL — Antonia Quirino sits with a dazed look on top of the stairs of her bamboo house amid a large swath of cornfield. She speaks laconically, as if every word is a labor. Filth surrounds her; debris of past meals remain on the dirty kitchen and table, the clotheslines display tiny clothes too grimy and stained to be considered ready for wear. Nearby, a few of her children sleep the day away.

At 40, Quirino is a mother of 10 children, and is four months away from giving birth to her 11th. She delivers at home and has known no prenatal or postnatal care, yet her nipa hut is just a few meters off the main road that leads to Bohol’s tourist-drawing resorts. She is a mother at risk, but she is below the radar of the government, which has sworn off providing free contraceptives, and which does not encourage information about their use.

About a 90-minute plane ride away, in Malacañang, sits a woman whose family planning policy, many say, has directly or indirectly consigned Quirino to her fate.

IT’S rice porridge for lunch for Antonia Quirino and her young brood. [photo by Jaileen Jimeno]

When she first took power in 2001, President Gloria Macapagal Arroyo initially issued confusing statements on her family planning policy. She once admitted using pills in her early years as a mother and wife, but said that as a Roman Catholic, it made her go to confession. In 2002, in an apparent effort to woo the Church, which supported her predecessor’s ouster, she ruled out the purchase of contraceptive materials and tossed the responsibility of buying these supplies to local governments. She has since fortified that policy to placate the Church as her government battled numerous threats to its survival. It has also resulted to the undue delegation of official power and handing over of state funds to a private group allied with the Church.

Government health workers and nongovernmental organizations (NGOs) exposed to the realities in the field say Arroyo’s position has deadly effects on numerous fronts. They say it keeps the poorest women uninformed of all the options available to them to limit or space their children. It deprives women of the free contraceptive materials previously available to them in barangay health centers. Worse, private groups like Couples for Christ (CFC), using government funds, preached against artificial contraception. This has prompted a longtime government health expert, who spoke on condition of anonymity, to warn of a rise in abortion rates because of the dearth of contraceptives, formerly available but now absent, in health centers.

“When the census numbers are out next year, this government will be shocked by the high incidence of abortion,” says the government health official. The same official is aghast at how women’s health is being regarded as just another political issue.

Dr. Junice Melgar, head of the NGO Linangan ng Kababaihan or Likhaan, also says that women’s health is now being sacrificed for political expediency. “This is her legacy,” she says, referring to President Arroyo. “Women will remember her harshly for this. This is a woman who has been very unkind. She is pushing women into unsafe pregnancies, and probably even death.”

In a paper that reported the effects of the contraceptive ban in the city of Manila, Likhaan noted that Arroyo “is the first president since 1969 to weld its policies not to medical standards, but to the moral standards of the (Roman) Catholic Church.” (See sidebar) Melgar also asserts, “The major battle is the president herself. It’s not just the Church, but the president’s own attitude toward women.”

Rise in unintended pregnancies

A 2006 study done by Josefina Cabigon of the University of the Philippines Population Institute (UPPI) and five other experts at the Alan Guttmacher Institute, an international NGO that focuses on sexual and reproductive rights worldwide, says that six in 10 Filipino women had an unintended pregnancy at some point in their lives because of lack of access to and knowledge of modern contraceptives. That fraction, says the study, translates to some 1.43 million unintended pregnancies each year, a third of which end in abortion.

It also says that while the women who had abortion come from all classes, the majority are “married, poor, and Catholic.” The study adds that poor women tend to use unsafe methods because they cannot afford safe procedures by trained providers. These unsafe methods include massage, insertion of a catheter, and the use of Misoprostol, which is prescribed by doctors to treat gastric ulcers. Eight of 10 of the women who use such methods suffer complications, says the study.

A July 2007 World Bank report on population issues also says that the main reason women in developing countries like the Philippines seek abortion is “often due to difficulties in obtaining access to an appropriate method of contraception, incorrect or inconsistent use of contraceptive methods, and contraceptive method failure.”

Meanwhile, the Department of Health (DOH) says it has reduced maternal deaths from 172 per 100,000 births in 1998 to 162 per 100,000 in 2006. But that still means 10 to 12 women die everyday, or around 3,650 to 4,380 every year, because of pregnancy and related cases. Originally, too, DOH had aimed to reduce the maternal mortality rate to 100 per 100,000 births by 2004.

Tomas Osias, head of the Commission on Population (Popcom), the state agency that determines the direction and implementation of the government’s family-planning programs, traces the maternal death rate to women being “too young (less than 18 years old), too old (over 34 years old), or having babies too close or unspaced (less than two years).”

Suneeta Mukherjee of the United Nations Population Fund (UNFPA) has also said that 99 percent of maternal deaths are preventable, adding that promoting family planning in places with high birth rates could help cut the maternal mortality rate by as much as 35 percent. Media reports last March also quoted her as saying that it is unlikely that the Philippines will meet its target of reducing the maternal mortality rate to 52 per 100,000 births by 2015 without “political will.”

As it is, NGOs even doubt the data on maternal health now in use by the DOH. Melgar explains that the maternal mortality rate of 162 per 100,000 is not the result of the regular census conducted every five years. She says it is the result of a survey, which has an error margin of plus or minus 30. This is because the president, whose much-vaunted field of expertise is economics, was not able to fund a census in 2005, because the budget was again re-enacted. A census is a basic requirement in economic planning, as well as in goal- and policy-setting.

Melgar says that veteran health department officials know it is critical to provide family-planning materials to women who want to plan how many children they will have and when, but who are unable to afford these materials on a regular basis. But Melgar asks, “How can you do that, (provide supplies) if your boss does not allow it?”

A YOUNG mother and her new-born wait for their number to be called at their community health center. [photo by Jaileen Jimeno]

No buying of artificial contraceptives

Last year, in fact, Albay Representative Edcel Lagman was able to insert a P180-million budget for contraceptives for 2007. But that money remains unspent, and Health Secretary Francisco Duque says it certainly will not be used for artificial contraceptives.

“We are not buying,” he told PCIJ recently. According to Duque, DOH’s policy against government spending on contraceptives will remain, and that his department aims to just “strengthen the scientific, natural family planning methods” it has espoused under the Arroyo administration.

In 2004, DOH even awarded P50 million to the religious group Couples for Christ to fund a government program called Responsible Parenthood-Natural Family Planning (RP-NFP). According to its own website, the CFC considers sex education, contraception, sterilization, in vitro fertilization, and population control as “anti-life.”

Couples for Christ was one of the first groups to mobilize its members during Edsa II, which resulted in the ouster of then President Joseph Estrada and Arroyo’s ascension to power. In a June 2004 report to then Health Secretary Manuel Dayrit to cover the first tranche of the money, CFC said it used the fund to conduct almost a hundred lectures on natural family planning, “chastity education” campus tours, and media and public relations expenses.

Lawyer Rhodora Roy Raterta, executive director of the Family Planning Organization of the Philippines (FPOP), says the deal violated the principle of separation of church and state, “as the CFC is known to have links with the Catholic Church.” But what made it worse, she says, were reports that CFC also used its trainings to denounce artificial contraception.

“The bottom line is, it’s wrong,” says Raterta. She also says that funding natural family planning alone violates the Constitutional provision that says the government will protect the right of spouses to found a family in accordance with their personal religious convictions.

Then Senator Luisa Ejercito, Estrada’s wife, was so incensed by the agreement between the DOH and the CFC that she filed a resolution demanding an investigation into its legality. She said the P50-million deal should have gone through bidding, like all other government contracts.

But health experts are also unhappy over CFC’s claims regarding the efficacy of natural family planning (NFP). Melgar says CFC does not tell its clients that “going natural” has a high failure rate of seven per 100 cases.

In a 1995 study by four experts led by Haishan Fu for the Alan Guttmacher Institute, abstinence, the core of natural family planning, was found to have a 22-percent failure rate while withdrawal had 26 percent. (The Standard Days Method, which the Church promotes, requires abstinence of up to 12 days.)

In comparison, says the study, implant and injectables have the lowest failure rates (two to four percent), followed by the pill (nine percent), the diaphragm and the cervical cap (13 percent), and the male condom (15 percent).

“It’s okay if women choose natural family planning methods,” says Melgar, who is Catholic. “But they should be advised that they could get pregnant, that it has a very high failure rate.”

Yet the CFC, in a letter to its members in October 2004 stated, “NFP is the most reliable, with 99-percent efficacy rate, proven in more than 100 countries and no side effects, except greater marital love and joy.”

Strategic appointments

Last year, Geraldine Padilla, wife of CFC director Frank Padilla, was appointed to the Popcom board, which is made up of 10 Cabinet members led by the health secretary, the UPPI director, and three private-sector representatives.

PRESIDENTIAL adviser on family matters Dr. Jose Sandejas believes despite the dismal chances at higher education of children belonging to big families, they will save the country as the next generation of overseas Filipino workers. [photo by Jaileen Jimeno]

As a state agency with almost four decades of experience, Popcom has built a strong network in all provinces, which could effectively reach all households, given enough funding and support. But Popcom has found itself unable to provide the whole array of options it used to offer women. In keeping with Arroyo’s ban on modern methods, its trainings are now limited to explaining women’s fertile periods and the natural methods of contraception. No lessons on artificial means are taught; should a woman ask for these, she is “referred to health centers,” says Popcom chief Osias.

What frustrates women’s rights advocates is the lack of a written, official government policy directive on the ban on contraceptives. This would have afforded them the right to question the policy in the courts. “Our problem is that our hands are tied,” says Likhaan’s Melgar. “There’s no executive order and it’s all verbal. GMA says ‘I am not funding,’ and it becomes the law.”

In 2002, however, the DOH did issue Administrative Order 125, which mandates government health workers to promote natural family planning as “the only acceptable mode of birth control.” It promotes the program under the battle cry of “responsible parenthood.”

Arroyo’s political accommodations in favor of the Catholic Church are also clear and out in the open, leaving even career government officials in fear of losing their jobs should they go against the anti-contraceptives policy.

Thus, they have kept their mouths shut even as the likes of Padilla were named to the Popcom. Padilla is also one of the commissioners of the National Commission on the Role of Filipino Women (NCRFW). (Weeks of efforts to interview her for this piece proved difficult, however, as no one at CFC, Popcom, and NCRFW seemed to know how to get in touch with her.)

Five years ago, Arroyo also appointed Jose Sandejas, who has a doctorate in materials engineering, as presidential adviser on family matters. Sandejas, aside from being a close adviser of Archbishop Paciano Aniceto of Pampanga, has been a trustee of Pro-Life Philippines since 1987. In 2006, he was also named commissioner of Popcom.

Sandejas says that for 37 years, the country pushed artificial contraception, which he says only benefited big pharmaceutical companies. He says that by promoting just the natural methods, the Arroyo government is merely trying to balance the equation. “The pharmaceutical companies make a lot of profit,” he says, “let them push it (artificial contraceptives).”

“It’s really the work of the devil,” he says of artificial contraceptives. “The devil’s main strategy is to create divorce, contraception, homosexuality. The enemy is really winning out so much.”

Rich and poor realities

Sandejas dismisses the notion that men tend to leave the responsibility of contraception to women, and that men find it difficult to comply with the abstention required of couples who opt for natural contraception. “I think the men would resent the accusation that they are like animals,” he says. He says most men are responsible, “even those who live in the slums, even the uneducated.”

Sandejas warns of a “demographic winter,” of a graying society with no young blood, of the “human race becoming extinct,” should all countries aggressively try to limit their population. With sadness in his voice, he notes that 50 years ago, Filipino families had an average of seven children; now the average is inching closer to just two children per family.

But experts say that average does not capture the reality of poorer households having more children than higher-income families. While the poorest 20 percent of Filipino women have an average of six to seven children, the richest 20 percent have an average of two.

The 2007 World Bank report on population issues also highlights the correlation between the number of children a woman gives birth to and her capacity to earn. “In the Philippines, the average income growth for women with one to three pregnancies was twice that of women who had undergone more than seven pregnancies,” it says. “Accordingly, the number of children a woman gives birth to affects her subsequent employment and income prospects, with the risk of further driving gender inequalities and perpetuating poverty.”

The report says that since a large family is unable to adequately invest in education, the setback “can create inequities in education and perpetuate poverty.”

With the odds stacked against women who belong to the poorest of the poor, the World Bank report calls on policymakers and development agencies to address inequities in the area of reproductive health.

NOW 95 years old, Dr. Fe del Mundo remains the doyenne of Filipino doctors, whose many accomplishments have changed the lives of millions of people. [photo by Fides Lim]

The black bouffant wig nods on her tiny, spare frame as she ticks off a simple diet mostly of fish and vegetables with little rice, plus a fondness for cheese. Yet there is more to this admittedly “lazy eater” who eats, she says, “because it’s there.”

Fe del Mundo, doyenne of Filipino doctors, is a woman of many firsts, whose many accomplishments have changed the lives of millions of people.

Married only to her profession, she however counts a multiple brood from generations down that she has variously embraced and they, her. They include not only those who were entrusted in her direct care, but also those whose lives she has touched and strengthened through rural rehydration and health centers, immunization campaigns against polio, measles and chickenpox, anti-tuberculosis programs, and a diarrhea treatment called BRAT (banana, rice, apple, tea) that has benefited and saved millions of children around the world.

There are also the hundreds of students who came under her tutelage — from the nursing school she set up at North General Hospital after the war, to her long teaching stint at the University of Santo Tomas (1943-1974) and chairing the pediatrics department at Far Eastern University (1956-1976), to the training centers and health institutes that she shepherded.

Then there are the 400 youngsters who became her special wards during the Japanese Occupation. The offspring of U.S., British, and other foreign nationals who were imprisoned upon the outbreak of the war, del Mundo with the help of the Red Cross set up a “Children’s Home” to care for these sick children in enemy-occupied Manila.

“I’m glad that I have been very much involved in the care of children, and that I have been relevant to them,” says del Mundo, in tones so soft one has to strain to hear her. “They are the most outstanding feature in my life.”

IT HAS been a life marked by both tragedy and triumph. The sixth of eight children of Paz Villanueva and Bernardo del Mundo, a prominent lawyer from Marinduque, the death in childhood of four of her siblings influenced her decision to take up medicine.

It was particularly the memory of youngest sister Elisa who died at seven years old from peritonitis, an abdominal infection, that firmed up her resolve to become a doctor. “She kept a little notebook where she wrote that she wanted to take up medicine,” recalls del Mundo. “When she died, I decided to take her place.”

In 1933, 22-year-old Fe graduated valedictorian from the University of the Philippines’ medical school. Financial problems nearly prevented her from finishing but a relative came to her rescue. In school, she observed that those who had textbooks hardly read them, while those who were hard-up like her would borrow and study the books whenever possible. But she says, “Monetary aspects have not been important considerations in my choice of direction or targets.”

The extremely shy girl who was known to cry when asked to speak before the class chose pediatrics as her field of specialization. Barely five feet and weighing less than a hundred pounds, she had often been advised by her medical professors that this was the best option as the patients would be smaller than she is.

THE hospital she founded and which bears her name unfortunately had to temporarily close down this week, hit by a strike. [photo by Fides Lim]

But it was her research work as an intern in her home province of Marinduque that sealed her decision. “I saw how many children were not receiving medical attention and how many were dying,” she recounts. “There was no doctor for children and the provincial health officer had no background at all about pediatrics.” She was dismayed when the health officer always gave the same diagnosis and advice for every sick child: “Oh, that’s worms. Give him a purgative!”

Those experiences sparked a serious interest that would develop into a lifelong commitment in the identification and treatment of childhood diseases and its prevention. She was to pioneer in this expanded role of pediatrics — from the prenatal care of mothers to the health and development of children through adolescence. And her grassroots immersion in Marinduque would lead her to further reach out to poor children in other doctorless remote areas.

She had to be creative in the struggle to save lives in a country where babies die from the most common yet preventable diseases. She is credited with devising an incubator for use in rural areas without electricity, as well as a cloth-suspended scale to weigh infants and a radiant warmer made of bamboo to regulate the body temperature of newborns with special care needs.

The makeshift incubator consisted of two native laundry baskets of different sizes placed one inside the other. “I put in hot water bottles all around between them. I put a little hood over it and attached oxygen for the baby,” she says. “We had to do with whatever was available.”

Driven by a thirst for knowledge and to expand her horizons, del Mundo sought and worked hard to obtain a study grant to the United States. In 1936, through an unexpected scholarship offer under President Manuel Quezon, she was accepted at Harvard University Medical School for postgraduate work.

She recalls with a chortle that when she went to the dormitory assigned her in Boston, she found herself in a men’s dorm. Unknowingly, Harvard — which would open its doors to women only in 1949 — had admitted a female to be part of its all-male student body. But because of her scholastic credentials, the pediatrics head saw no reason to send her back. Thus, she became the first Filipino woman and the only female at the time to be enrolled at the Harvard Medical School.

POSTGRADUATE STUDIES in pediatrics at Harvard, Boston, and Columbia Universities led to a residency at Billings Hospital in Chicago and a research fellowship at Harvard Medical School. But on the eve of World War II, despite attractive opportunities to remain in the United States, del Mundo returned home. “I told the Americans who wanted me to stay that I prefer to go home and help the children in my own country,” says the doctora. “I know that with my training for five years at Harvard and different medical institutions in America, I can do much.”

BANNER displayed at the hospital enumerates its founder’s legacy of excellence and commitment. [photo by Fides Lim]

This would become the pattern in her life. Between returning to the Philippines and staying in the United States, which she would revisit many times after the war for study tours and conferences, she always chose readily to go back home, where she wanted to do much more. She considered her trips abroad more as learning missions and for fund-raising to realize her dream of setting up a full-fledged pediatric center for both curative and preventive medicine.

Before that dream was realized, though, she first came to be called the “Angel of Santo Tomas” for her work with women and children during the Second World War. Initially housed at the Red Cross building near the University of Sto. Tomas (UST) internment camp, the “Children’s Home” she set up transferred to bigger quarters at the nearby Holy Ghost College (now Holy Spirit) when the number of patients grew to include expectant, convalescent, and nursing mothers. The makeshift hospice lasted from 1942 until 1944, when it was shut down after the Japanese ordered all the women and children back into UST.

After the war, del Mundo received commendations from the former prisoners and the U.S. government for extraordinary heroism in action. She would continue to receive letters and visits from her grateful wards for her courageous work.

But her one big dream became a reality at last on November 27, 1957, her birthday. With an P800,000 loan from the Government Service Insurance System (GSIS), some donations, and the proceeds from the sale of her first house, the 100-bed Children’s Memorial Hospital finally opened to serve the public. She patterned the hospital set-up after a facility she had admired in Chicago.

Just as she had moved into a new house, she sold this to build her hospital’s adult wing. She again had to sell yet another home to fund the construction of another unit of the hospital, the Institute of Maternal and Child Health. Inaugurated in 1972, this was the first of its kind in Asia dedicated to preventive medicine, training and research, and rural extension work.

Years before, in 1958, she had signed away personal ownership of the hospital and turned it over to a board of trustees. She was able to pay back her loans.

She continues to donate the fees from her own practice to support the 30-bed charity ward — much in the same way that she had invested much of her own money along with her time and talents in all the previous hospitals she headed. In 1948, when she left the North General Hospital as director and senior pediatrician, she had scarcely enough funds to pay for moving out her belongings. But as she once said, “While the specialty of pediatrics is far from rewarding in terms of financial returns, the satisfaction derived from guiding and serving children is worth much more than a check for services rendered.”

THESE DAYS, a wheelchair aids del Mundo’s movements. But it has not constrained her from fulfilling a tour of duty that has lasted 70 years — and still counting.

Every morning, barring the worst of weather or a rare bout of illness, she still rises at five to catch the early mass at Sto. Domingo or nearby churches. Then it’s back to the hospital she founded that was recently renamed after her in recognition of her innumerable contributions to pediatric and maternal care.

The hospital compound along busy Banawe St., Quezon City is also home to del Mundo. She lives in a modest little suite at the east wing of the second floor of the main building. She still remembers the early years when she had to move herself and the staff members who were living with her from floor to floor as the hospital was being built.

Today the once dizzying spin of lectures, hospital calls, conferences, and yet more meetings has come to a pause, along with the once endless cups of black coffee. But the line of young patients has not shortened as parents or grandparents that were former patients still ask for her personal services. And the doctora still prepares the “history of the day” and makes her rounds.

“I’m glad I never got married,” says del Mundo. “I believe that I’ve been able to do what I’ve longed to do because of this.”

A COMMENDATION from her alma mater, the University ofthe Philippines, hangs on one of the hospital’s walls. [photo by Fides Lim]

She remains forward-thinking and open-minded, even when it comes to population issues. A devout Catholic born and raised just beside the Manila Cathedral in Intramuros, she ranks religion as “the greatest influence” in her life. But she sees no conflict between practicing her faith and pursuing family planning programs that are opposed by Catholic church elders.

Apparently, she shares the belief that improving the quality of life of the poor means addressing the problem of unregulated birth rate. Even before the government began encouraging population control in the late 1960s, del Mundo had rural units in distant Palawan and Marinduque teaching family planning, reproductive and sexual health, and proper nutrition.

“I think that we can control population but still remain true to our religion,” she says simply.

Del Mundo is an avid believer as well in harnessing the role of the community and the importance of the team approach to primary health care. With her rural extension teams, she has traveled far and wide, enduring often primitive conditions, to instruct mothers on breastfeeding and to undertake the regular weighing of children under five and periodic examinations of water supplies.

Her own clinical studies include 150 scientific papers that range broadly from the measurements of 10,839 newborn babies and commonly missed children’s diseases to the pathogenesis of dengue fever and on immunization.

To her, the pediatrician must be “community-oriented and community-involved,” if they are to achieve the best possible health care for the youth. “Medical students must go out into the provinces to see firsthand the problems that exist,” she insists. “Pediatricians must be able to translate medical knowledge into a language their patients will understand. Only in this way can a doctor acquaint their patients with the importance of preventive as well as curative medicine.”

She notes that most pediatricians are women, proving that they have assumed this role well. “Women make good pediatricians and they can very much influence parents in the care of children,” she told the Medical Observer. “I feel that if you give the world the best that you can, the best will always come back to you.”

DEL MUNDO’S manifold services to children everywhere have brought her repeated honors. These numerous awards, citations, and plaques are proudly showcased all around the hospital she established, which will retain her name even though it was sold just last month to Accent/STI.

One award close to her heart is the Ramon Magsaysay Award for Public Service she received in 1977, in recognition of “her lifelong dedication as a physician extraordinary to needy Filipino children.”

“It came to me as a big surprise,” she says of the award. “And I’m very grateful.” An admirer of President Magsaysay, she recalls meeting him, but almost very casually. “He talked to me more than twice, saying that my brother (Salvador) was his former professor in chemistry, and my brother was very strict and almost failed him,” she says. “I told him I’m sorry, but I’d no idea.”

But the heaps of honors and praises have not turned her head or made del Mundo lose sight of her purpose. “I had the opportunity more than others,” she says. “Why should I be proud? It does not make me feel different. I have remained the same in my daily life.”

A lifetime of achievement has also failed to make this “medical stateswoman” consider casting her stethoscope into the murky world of politics. “Never,” she quickly replies. “I do not love to talk, or say more than what is expected of me. I’m very quiet.”

She was probably upset when her beloved hospital was hit by a strike last week, forcing doctors to double as clerks and cooks just to keep it going. (They still had to send most of their patients home, and by last Monday, the hospital had to temporarily close down.) But what really causes great concern for the woman whose name translates to “Faith of the World” is the impact on the marginalized of the increasing number of Filipino doctors and nurses leaving for abroad. “The work I’m doing here in this hospital serves very few,” she says. “It does not reach the hinterland where most help is needed.”

She adds wistfully, “I wish I could still go out into all nooks and corners of the country and bring better care for children.”

That, she says, is her only regret at 95.

Fides Lim also wrote Dr. Fe del Mundo’s profile in the forthcoming Great Men and Women of Asia Volume 7, a Ramon Magsaysay Award Foundation publication that is due for release at the end of August. The book is part of a series honoring Magsaysay awardees.

Half a year later, however, my daughter’s x-rays showed clear lungs, thanks to the care and treatment she got from her doctors. And all it cost to get her well was essentially the price of a bus ticket to Baguio, plus the jeepney fare to my family home in Benguet.

The author with daughter Isis

Okay, so I figured going home to Benguet was about the only option I had then. After all, I had just quit my job, because while the pay was fair and was not too far away from what most Filipino writers/researchers get, it still wasn’t enough to support a growing infant — much less a sickly one. I was working in Quezon City, away from my family in Benguet province, so half of my monthly take was going to rent a small but decent place in the city’s poorer quarters. The other half came to some $3 a day (1999 figures), which, when divided between my daughter and I, would have kept us just a tad away from falling into the ranks of the absolutely poor, or those marked by the development agencies as earning or spending $1/ day or less.

My other confession is that the diagnosis was issued by doctors at St. Luke’s Medical Center in Quezon City, one of the country’s premier — and expensive — hospitals. I may have been hard up, but there was no way I would leave my daughter’s welfare to a public hospital here in Metro Manila. All my experiences with public hospitals in the metropolis bordered on horror stories, without exaggeration. I’m sure that many others have horror stories of their own; the state of Metro Manila’s public health care system is another reason that makes urban poverty so appalling.

I did try a public health facility once, when my daughter first came down with pneumonia, coupled with gastroenteritis. I brought her to the Lungsod ng Kabataan in Quezon City, but the long lines and the way people were being treated there only made me realize real quick that money really talks in the big city. And so I pulled my daughter out and brought her to St. Luke’s, even when I knew this would wipe out my savings. Health is precarious in children before age five, and I certainly did not want my daughter to add to the ranks of the six million or so children who die before the age of five because of completely preventable causes like pneumonia. (Yes, these words actually scurried like frantic mice through my mind at the time, remnants of research I did years back for a PCIJ book on children and the media.)

Anyway, like everyone who has been to St. Luke’s, I paid a fortune for her five-day stay (at the ward). But the sense of security one gets from a hospital with a good reputation can be priceless: as soon as I walked into the emergency ward and we were immediately attended to, I felt reassured that my daughter would be cared for. When bill-paying time came, however, I noticed that even just the stick used to press my daughter’s tongue down (she used several) had a price tag.

That’s when a bus ticket home became part of the prescription to nurse my daughter back to health.

INITIALLY, GOING back home was partly about finding a rent-free place where I could continue to breastfeed and cut down on other expenses. But it was also about finding a place where free anti-TB medications might be easier to get, and where there were more relatives to run to. I never got those free medications, but I was certainly able to keep costs down.

Consider: In Manila, after the rent was paid, the utilities and transportation budgeted, would there have been enough left of my pay to buy infant formula — a kilo a week, at the least, if I remember right? And what about childcare, would there be enough money for that? And would it be possible to find someone who would religiously give my daughter her medications every single day — totally needed to eradicate the developing TB?

Back in the ancestral home, I was jobless. But for the next eight months, I was able to survive on doleouts from friends and relatives that came to somewhere a little above the $2/day threshold. This was virtually the same amount I would have earned back in Manila, but now it bought a higher quality of life for both me and my child.

For one, going back to purely breastfeeding her, which I could not do while holding down a job fulltime, meant no more money went out for infant formula. It also meant that her health began to improve quickly.

In Manila, a monthly check-up with the private doctor would have cost P250 for the consultation alone, but generally ended up with my having to shell out some P500 to P1,000 for inoculations, vitamins, and such. In Benguet, weekly check-ups were free. The basic inoculations were also free, plus easier to access, with less people in a Benguet municipal health center compared to one in any of Quezon City’s thickly populated centers.

Because I wanted to be certain my daughter was getting the best possible treatment, we alternated between going to the charity ward of St. Louis University Sacred Heart Hospital and the newly built Benguet General Hospital, which was walking distance from where we lived. At Sacred Heart, all resident doctors and interns work both the pay and charity units. Since many politicians and well-known Baguio citizens go to this hospital, I was assured that specialists (and pediatricians) there would at best be qualified, and at the least be careful. The doctors and nurses at the government-run Benguet General Hospital also turned out to be well-qualified, although many of them were just waiting for their papers to go abroad.

Yet it was not just about qualifications, but also about the quality of care my daughter got, which was outstanding in both hospitals. Perhaps one reason for this is that the average number of patients the doctors had to see in a single day was not too big, and they thus did not end up too harassed. And because Benguet is not a commercialized a place (it got its McDonald’s only at the beginning of the new millennium), the low pay must have been less of a bother to these Benguet doctors. But whatever the reason, the doctors there were easier to talk to: I was able to ask questions about my daughter’s condition, and was even taught alternative ways of caring for her. Many of the Benguet and Baguio doctors, too, acted like the sort of family doctors you would see on TV or in the movies, comforting crying babies, playing with toddlers — the works…and the sort of thing that I don’t see at all in public hospitals in Metro Manila.

EVEN IN terms of medications, there was quite a big difference in cost and quality here and in Benguet. In Manila, for each bout of upper respiratory tract infection — and there are many in a child who has primary complex — the doctor would prescribe one medicine for the clogged nose, one for the cough, and one for the infection. In contrast, doctors in Baguio/Benguet were more inclined to do things the natural way, which tends to be cheaper and actually safer. They were in fact quite appalled by her medical record and told me that she had been given “third-generation cephalosporins” that they felt was not necessary, since the use of conventional antibiotics had not been ruled out as effective. Also the third-gen stuff was far stronger, more expensive, and branded. I suspect more doctors in the big city are tempted by the perks and benefits they get from pharmaceutical companies. Or perhaps it’s just a matter of perspective. But for sure, the Baguio/Benguet method was clearly more effective for a poor and developing community.

So it was back to the simpler stuff for my daughter and me: erythromycin (as our family is allergic to penicillin) for the infection, steam inhalation for the clogged nose. I was also taught how to do the “bronchial tap” or the tapping of the back to loosen phlegm trapped in the lungs. And of course the anti-TB meds.

On top of these, fees for laboratory work — such as urine tests or x-rays — were half the price of those I paid for at St. Luke’s. And they were about a third cheaper at Benguet General Hospital. An x-ray, for example, was some P400 (in 1999) in St. Luke’s; it cost about P200 in Sacred Heart Hospital in Baguio and around P160 in Benguet General Hospital. I’m not an expert in the medical field, but I didn’t see much of a quality difference between the x-ray itself and the interpretations in all three places.

By the time I brought my daughter down again to Manila (where the jobs for writers are, alas, despite the higher cost of living) eight months later, she was healthy. She would stay healthy and, as bonus, seemed to have benefited from the extra care and early childhood teaching I would have only been able to do in more relaxed Benguet. When it was time for her to go to school, she was the first in her 3′s class (three-year-olds) to be able to write her name. Her teacher also said she had a “huge stock knowledge of concepts” for her age. Today she is a lively, independent and smart eight-year-old who has not been sick with any major respiratory illness since her recuperation in Benguet.

In retrospect, it seems to me that Benguet province shares my story: in the 1970s and 80s, Benguet used to be among the country’s poorer provinces. For many years until 1997, it had been among the country’s 20 poorest provinces.

But nine years ago, Benguet was able to pull itself out of that rut. Today it stands proudly as the only province in the Cordillera Administrative Region that is not found among the country’s 44 poorest provinces. Despite the fact that its economy today is hit hard by the freer importation of potatoes, beans and other Baguio vegetables from cheaper and better subsidized farms in China and elsewhere.

In 1999, it was even considered as the country’s top 8th province in terms of quality of life. This was according to the group of economic activists at Action for Economic Reforms.

For me, this only shows that having the right kind of information and focusing on priorities can spell the difference between abject poverty and a simple but quality life.

The author believes that if health officials muster enough political will, this alone could improve the country’s healthcare system by leaps and bounds.

BREAST IS BEST. Mothers and their babies set a new world record for simultaneous breastfeeding at the San Andres Complex in Manila last May 4, 2006. [photo courtesy of P. Repelente, DOH]

BREAST OR bottle?

That may seem a no-brainer to many, but it’s a question that’s still throwing mothers, activists, government officials, medical experts, milk manufacturers, and apparently even U.S. diplomats in the throes of deep distress. To think that two decades ago, health officials had considered the matter already settled with the passage of the groundbreaking Milk Code, which aimed to protect breastfeeding and regulate the promotion of breast-milk substitutes. Yet officials say that instead of seeing more mothers breastfeed, the opposite has been happening. And those who still breastfeed are doing so for shorter periods of time.

“The norm now is infant formula, not breastfeeding,” laments health undersecretary Alexander Padilla. “The situation is tragic as it is desperate.”

Health experts say that as a result, many children are being denied the best nourishment freely available to them. They add that these children are made more vulnerable to falling ill, and mothers themselves are unable to take advantage of the health benefits of breastfeeding.

Blame the aggressive marketing of manufactured milk products, say government officials and breastfeeding advocates. But both also admit that the lack of education about breastfeeding and a frail legal environment are contributing factors, too, to the feeding bottle’s ever-growing popularity.

Yet the trend isn’t exactly new. Medical anthropologist and health activist Michael Tan points out that in 1963, the average period of breastfeeding in the country was 14.5 months; by 1982, it had dropped to 12.1 months. Tan guesses, though, that these survey data likely referred to breastfeeding in general, meaning it includes the weaning period where other foods are introduced to the baby, and not exclusive breastfeeding.

Exclusive breastfeeding means breast milk is the only food and drink given to the infant; not even water is given. The international standard for how long this should last is six months. But based on the two latest rounds of the National Demographic and Health Survey, Filipino mothers hardly come close to reaching that. In 2003, the median period for exclusive breastfeeding in this country was a mere 1.4 months. By 2003, the figure has declined to 0.8 months.

In 1998, a quarter of Filipino mothers exclusively breastfed their children for the first six months. Today that proportion is down to 16 percent.

Health officials have been working double time to increase that number. They also want more mothers breastfeeding until their children turn two years old. Last July, in fact, more stringent implementing rules for the Milk Code — known formally as Executive Order 51 — would have taken effect. But then several milk manufacturers went to court, arguing that the health department had overstepped its bounds. It should have left rulemaking to Congress, said the milk companies. They also said they were being deprived of their right to unrestrained trade.

Initially, the Supreme Court ruled in favor of the health department. But just a few weeks later — much to the consternation of health officials — it reversed itself and granted a temporary restraining order on the implementation of the new Milk Code rules. Legal experts, though, predict that it may take some time before a clear winner emerges from the court battle.

TO MANY people, it had seemed like breastfeeding advocates had already won the war. When this writer undertook an informal poll among her friends in their 30s, for instance, all of the 15 mothers who responded had tried breastfeeding. Most of them also said they knew breastfeeding brought immense health benefits to their children. (See highlights of survey.)

One even felt guilty for being unable to feed only breast milk to her baby. “I didn’t have enough milk to breastfeed him exclusively,” said lawyer Andrea Pasion. “I’ve had guilt feelings about this. I even bought expensive feeding bottles, those with teats that are supposedly similar to real nipples. I really had very little milk — and I had two breast pumps ha.” She said she hoped it would be “better with my next pregnancy.”

Since 1986, all infant formula ads, whether print or broadcast, have had to carry the message, “Breast milk is best for babies.” It was no empty claim; the Department of Health (DOH) says breastfeeding could prevent up to 16,000 infant deaths each year in the Philippines. The UK medical journal Lancet has also said that breastfeeding can prevent over 10 percent of child deaths worldwide.

Under the Milk Code, all milk ads have had to be approved by an inter-agency committee, which monitors violations as well. In addition, baby-food companies cannot give away samples and supplies of their products and “gifts of any sort” to the general public, to health institutions (including hospitals), and to “personnel within the health care system.”

Milk manufacturers are refrained from having containers and labels of their breast-milk “idealize” the use of infant formula. Containers and labels have to have a statement on the superiority of breastfeeding.

Since 1992, the Rooming-in and Breastfeeding Act has been in force, providing more push to the government’s breastfeeding campaign. The law requires hospitals to room-in newborn infants with their mothers — those delivered normally, within 30 minutes after birth, and those by C-section, within three to four hours — so that breastfeeding could be initiated.

But the likes of Tan, along with health officials, say all these have been undermined by milk manufacturers, which have remained as aggressive as ever. Indeed, the Bureau of Food and Drugs (BFAD) says that between July 2001 and December 2004 alone, there were 63 violations of the Milk Code. Alessandro Iellamo, the World Health Organization’s (WHO) nutrition consultant for the Philippines, says the BFAD tally “is even small, taken in the context of all the other violations that have gone on since 1986.”

Most of the violations BFAD recorded involved the distribution of print advertisements without proper approval by the inter-agency committee. There were also companies that used clinics and hospitals to promote their products, gave out samples to mothers, or printed unacceptable covers in reading material.

Tan is aware mothers choose not to breastfeed for a variety of reasons. “More often though,” he says, “Filipino couples think that infant formula is superior to breastfeeding, and spend hard-earned money — up to P1,000 a week — on the milk powder. The reason is simple: They’re victims of the relentless marketing campaigns of the milk companies.”

Still, health undersecretary Padilla himself concedes, “We have failed to implement the true intent and spirit of the law.” But it is precisely because of this, he says, that a revision of the Milk Code’s governing rules became crucial.

He also notes that when the health department, in consultation with WHO, the United Nations Children’s Fund (Unicef), and local breastfeeding advocates, began a process of updating these rules more than two years ago, the milk companies were represented in the public consultations.

“There were always these diametrically opposed views,” says Padilla, who chaired the committee that drafted the revisions. “We had to take a stand, and sometimes we had to compromise.” (Read a transcript of PCIJ’s interview with Padilla.)

The revisions were completed after 19 drafts. In May, the entire health council, headed by Health Secretary Francisco Duque III, signed the revised implementing rules through Administrative Order No. 2006-0012.

“IT MUST be stated for the record that the Milk Industry is in full support of the Milk Code and the government’s breastfeeding campaign, ” said the Pharmaceutical and Health Care Association of the Philippines (PHAP) in the petition it filed with the Supreme Court on June 28, seeking to prevent the implementation of the Code’s revised rules. (View petition, in pdf files, 1, 2, 3, and 4.)

“In fact,” said the group, “it has poured its own resources to supplement the meager P1 million fund allotted by the government for the said campaign. However, even as the Industry concedes the need to put more teeth in the Milk Code to further its effectiveness, the same must be done legally by means of legislative action, and not by mere issuance of administrative rules and regulation.”

PHAP head Leo Wassmer Jr. declined PCIJ’s request for an interview. In its petition, though, the PHAP, whose members include U.S.-based transnationals Abbott Laboratories, Wyeth Philippines, and Mead Johnson, said the revised rules’ premise that breastfeeding substitutes are hazardous to health and that there is no substitute or replacement for breast milk is “fundamentally flawed.”

“The impetus of the Milk Code was precisely to regulate the proper use of breastmilk substitutes, in recognition of the fact that in certain instances breastfeeding is not appropriate or possible,” it said.

The PHAP repeated these arguments in its motion for reconsideration. It also quoted a position paper from the Department of Trade and Industry (DTI) that said the revised rules, if enacted, would be “an infringement of the fundamental right of consumers to information and freedom of choice,” and result in the “damage of the infant formula sub-sector which employs a substantial number of Filipino employees.”

The PHAP estimates that displaced employees would reach 1,500. It says the proposed changes may cost its members to lose some P9.96 billion in all, including a P3.5-billion tab that would come from the “destruction of existing non-compliant inventory, withdrawal and destruction of trade stock due to non-compliant labels, and write-off of existing and pre-ordered packaging materials including, among others, tin, cartons cans, tin plates, plastic caps, labels.”

“But we are not asking the milk companies to destroy their products,” says Padilla. “The (revised rules cover) advertising, and promotional materials. If at all, what they will be changing are the labels. Not the products themselves.”

The revised rules in part ban the advertising, promotion, sponsorships, or marketing materials and activities for breast milk substitutes intended for infants and young children up to 24 months. Among the strictest prohibition perhaps is an “absolute” ban on “all health and nutritional claims for products within scope of the Code,” including “any phrase or words that connote to increase emotional, intellectual abilities of the infant and young child.”

The rules even disallow the use of pictures of babies and children with their mothers, fathers, siblings, grandparents, other relatives or caregivers in any advertisements for infant formula and breast milk supplements — as these would tend to “idealize” their use.

“OF COURSE they didn’t want to diminish their market, ” harrumphs Health Secretary Duque, who says he is not surprised that milk manufacturers are putting up a fierce fight. “They don’t want their bottom lines affected.” (Read a transcript of PCIJ’s interview with Duque.)

He confirms reports that officials of the U.S. Embassy and U.S. State Department talked to him, as well as to Trade Secretary Peter Favila about the changes in the rules. “They wanted the old provisions of the law, that they be reflected as is in the implementing rules and regulations,” Duque recalls. “We could not agree. Those were the very loopholes that existed and allowed them to go around the (rules).”

Responding by e-mail to the PCIJ’s query about the matter, U.S. Embassy Information Officer Matt Lussenhop wrote: “The U.S. believes that infant health is very important and that breast-feeding should be the first choice for infant nutrition. We support the broadest possible availability of information and educational materials regarding infant health.”

“At the same time, ” he continued, “this is an important issue that concerns a number of interested parties including private industry. We encourage the government of the Philippines to make regulatory decisions and rulings in a transparent manner that incorporate the concerns and views of all interested parties, including private industry, as an important principle in developing sound public policies.” (View a transcript of PCIJ’s communication with Lussenhop.)

But breastfeeding advocates say the milk companies and their supporters are simply too preoccupied with protecting, well, a cash cow. The DOH estimates the Philippine market of breast-milk substitutes is worth P21 billion ($400 million) annually. Padilla cites BFAD figures that show that in the last five years alone, there have been some 139 infant-formula products introduced in the Philippine market.

“The Philippines market is something (the milk companies) care for,” says WHO’s Iellamo. “Their interest is here.” He says Cambodia recently went through a similar process of legislating the regulation of breast-milk substitutes — “with very little resistance” from the milk industry. Iellamo notes that in contrast to the Philippines’ high birth rates, Cambodia sees only 300,000 newborns every year. Official statistics show that each year, some 2.5 million babies are born in the Philippines.

AC Nielsen Media Research says that the total advertising expenditures for powdered milk products in the Philippines was around P2.3 billion in the first half of this year alone. Milk-product advertising ranked sixth in AC Nielsen’s top ten ad big spenders. Nielsen executive director Jay Bautista told BusinessWorld recently, “These products cater to the biggest segment of our population. About 23 percent of our total population (82 million) are nine years old and below.”

Yet it’s not as if the efforts of breastfeeding advocates have been for naught. Reenalee Imperial, for one, is such a believer in breastfeeding that she did not let her infant son Joaqui’s inability to suckle stop her from giving him her milk. She would express and store it until it was time to feed Joaqui, who had a congenital heart ailment. The boy got his mother’s milk through a tube.

But the increasing pressures of a fast-paced lifestyle in a deteriorating economy seem to be pushing more mothers, especially those who work outside the home, toward milk formulas instead. Some do start their babies on breast milk, but then switch to formulas once they return to work. In all probability, a mother who commutes to work would find it difficult to lug around a breast pump, sterilized bottles, and a mini cooler (to keep the expressed milk fresh).

Some mothers also get frustrated when they cannot express as much milk as their babies seem to need. Breastfeeding can be painful for some women as well. Discouraged, they give up on the practice early.

YET HEALTH officials are hopeful an “enabling environment” could have even such mothers suckling their infants for longer periods. Says Secretary Duque: “(You)…have to work on the infrastructure, the social marketing and advocacy — convincing the public at large about the superior qualities of breastfeeding.”

It could help if more medical professionals pointed out those “superior qualities” to patients. Among this writer’s poll of 15 mothers, all of whom belong to the middle class, only eight said their obstetrician-gynecologists provided them with adequate information about breastfeeding. A mother who said her doctor gave her not only lectures, but also literature and strong encouragement for her to breastfeed, is based in the States.

As for what Duque refers to as “infrastructure,” some pending proposals in Congress do address this. Set to be filed at the House of Representatives is the Working Mothers Breastfeeding Act, which aims to provide tax incentives to companies that set up lactation rooms for their employees. Another bill, the Family Support for Breastfeeding Act, would require couples to undergo breastfeeding-counseling seminars before getting married.

In the city of Manila, meanwhile, social-work officials plan to have a milk bank that would store breast milk for babies whose mothers work outside the home. Earlier this year, too, Manila made a highly publicized pitch for breastfeeding, with 3,738 mothers taking part in a record-breaking simultaneous breastfeeding. (View a DOH photo gallery of that event.) Then on the last day of August, Quezon City saw an army of about 200 mothers and their babies swarm the grounds of City Hall, promising to advance breastfeeding. (The nongovernment group Arugaan organized the event, with the help of the local government and Unicef. View a slide show.)

Malls have joined in as well, thanks to incessant lobbying by breastfeeding advocates. Last March, SM Megamall in Pasig City opened a breastfeeding station. Five months later, the new Mall of Asia in Pasay followed suit. There is a similar set-up in Davao’s NCCC Mall — the first to have one in Mindanao. (View photographs of the breastfeeding stations of Mall of Asia and NCCC.)

When the PCIJ recently visited the Mall of Asia’s breastfeeding station, it had at least five mothers busy with their babies every half-hour. But one pregnant woman apparently just popped in to check out the room. She said she had breastfed her first child (now 11 years old), and was planning to do the same with the second.

“I would breastfeed anywhere,” she also said, recalling her experience with her firstborn. “I didn’t need a breastfeeding station.”

Today’s youth are exposed to sex and sexuality earlier and in larger doses.

UP A FLIGHT of stairs, in a room with red, yellow, purple, and green walls, the talk is all about sex, all of the time. This is, after all, the hotline center of the Teen Foundation for Adolescent Development (FAD), an organization dedicated to adolescent health. In this room, among a few potted plants, counselors are always ready to answer calls from youths and discuss with them the consequences of premarital or unprotected sex.

In the past, typical hotline questions involved girl-boy relationships and family, school, and peer issues. But in the last year alone, the number of inquiries about sexually transmitted infections (STI) has soared. It now ranks third among the top five most commonly asked issues.

“It’s very alarming,” says Cecilia Villa, president of FAD, which has its offices right smack in the heart of Manila’s university belt. Awareness is higher now, she explains, but very few people realize they can be infected with a disease because of one mistaken assumption or a momentary lapse of judgment. With the invincibility characteristic of the young, they “know about it but don’t think it can happen to them.”

Dr. Rosendo Roque, head of adolescent health of the Philippine Obstetrical and Gynecological Society (POGS), is himself quite worried. There is a lack of statistics and woeful underreporting, but based on feedback from obstetricians and gynecologists across the country and from his private practice, Roque believes STIs among youth is a growing health concern.

STIs are infections of the reproductive system, transmitted through sexual contact generally through warm, moist mucous membranes such as the vagina, anus, urethra, and the mouth. “STI” is used interchangeably with the more common term STD” or sexually transmitted disease. Some organizations, including the Department of Health (DOH) and the World Health Organization, are now using the more politically correct STI. The most common STIs diagnosed are gonorrhea, known in the vernacular as tulo, chlamydia, trichomoniasis, genital herpes, and genital warts.

There are many factors behind the increase of STIs, says Dr. Teresita Brion, an ob-gyn at St. Luke’s Hospital in Quezon City. “There’s the media. There’s the barkada. There’s the breakdown of families. You don’t need hormones surging to want to experiment.”

There is certainly no lack of stimuli either. Today’s youth are exposed to sex and sexuality earlier and in larger doses. There may still be the constant nagging of elders about sex being a sin, but between advertisements using sex to sell products, double entendres on noontime variety shows, and pirated pornographic DVDs sold for less than P80 in Quiapo to gyrating MTV starlets and explicit lyrics of hip-hop songs, young people are constantly bombarded with messages about sex. These contribute to a shift in cultural values that makes casual sex more permissible and traditional preconditions for sex such as marriage or true love increasingly irrelevant.

As a result, Filipino youths are having sex earlier. Last year, Roque’s youngest patient was all of 14. This year he has a 12-year-old. Brion sees patients who are sexually active even before their first menstrual cycle. According to the 2002 Young Adult Fertility and Sexuality (YAFS) survey of the University of the Philippines Population Institute, the average age for the first sexual encounter for both men and women is 18. About 55 percent of these first sexual experiences were not planned or were something the teenagers did not want to happen at that time.

Premarital sex is also becoming more accepted, its prevalence rising from 18 percent in 1994 to 23 percent in 2002. But the sex is often unplanned, sporadic, or a product of either being nadala (carried away) or peer pressure. It often takes place before teens learn about STIs and other health risks. “They still don’t know what is going on in them,” says Roque. “Most of them are getting into it because of peer pressure or experimentation. They are not well-guided.”

He also cites the impact of broken families, absentee parents, and lack of role models created by the mass exodus of Filipinos overseas. Parents abroad shower their children with gifts in order to compensate for their absence, so the children grow up in an nvironment of material excess without proper guidance. In today’s sexually charged landscape, there is a surfeit of teenagers left on their own to figure out their own values.

Dr. Brion suspects that experimentation on bisexuality and homosexuality, as well as one-night stands and having sex “for old times’ sake” or “just because” have become increasingly common. And while the dominant practice is still to have a single partner, there is a trend toward multiple partners, especially among young men. YAFS data show that about 50 percent of men have had multiple sex partners compared to about 11 percent of women.

THE CALLERS of FAD’s phone-a-friend hotline are a good mix of students and young professionals. Most are male. One possible reason is because males are more likely to have multiple partners and are therefore more vulnerable to contracting an STI.

At the same time, some STIs tend to be asymptomatic among women. Only 20 percent of women, for example, exhibit symptoms of gonorrhea; just half show symptoms of trichomoniasis, which is marked by painful, burning urination and a yellowgreen discharge among females.

STIs become a serious public health concern when ignored: in women, gonorrhea can lead to pelvic inflammatory disease, which increases the risk of infertility and ectopic pregnancy. Chlamydia, left untreated, can spread to the upper reproductive tract and in women, infect the uterus, fallopian tubes and ovaries, leading to infertility. Untreated syphilis may lead to nerve damage, mental disorientation, and eventually death. Yet approximately 80 percent of men and women who experience reproductive health complaints such as painful urination, abnormal vaginal/penile discharge, genital warts, or ulcers do not even consult a health professional.

This may be partly why the official number of STI cases in the country seems deceptively low. The 2003 National Demographic and Health Survey, for instance, says only 7.6 percent of men aged 15-19 and less than 2.2 percent of those aged 20-49 reported an STI or STI symptoms. But underreporting may be at work here; while public health centers usually report the STI to the health department for statistical purposes and the necessary contact tracing, private clinics are not obliged to do the same.

Even patients of private clinics rarely openly acknowledge their sexual practices or articulate the suspicion they might have an STI. And the young, for instance, would not tell their parents they think they may an infection because of what this may imply about their sex lives (which their parents often assume they don’t have). But they also might be too embarrassed to tell their barkada so they go on the Internet and self-medicate. The good news is that some STIs like gonorrhea and chlamydia are responsive to antibiotics. The bad news is that with self-medication, these drugs have been abused by over medication, under medication, wrong dosage, or prematurely stopping medication before the required time frame. As a result, doctors say they are beginning to see strains that are resistant to antibiotics.

When Lina (not her real name) experienced a burning, itching sensation while peeing two months ago, the first person she consulted was her yaya. The 18-year-old’s trusted nanny told her to use a feminine hygiene wash and put a hot water bottle on her tummy before sleeping. But the symptoms — which by then included an abnormal yellowish discharge — did not ease; Lina thought it was time to consult a doctor, by herself.

Lina was shocked when the doctor told her she had gonorrhea. She is sexually active, she admits, but has been with only one partner, her high school sweetheart. They have been together for four years. Now she believes he has been unfaithful to her and gave her gonorrhea.

Lina says she had planned to wait until marriage to have sex but college, with its accompanying independence, freedom, and openness of thought, challenged her long-held traditional beliefs. “Suddenly it’s ok to be affectionate with your boyfriend,” she says. “It’s ok to have sex with your boyfriend because everyone is doing it.”

They did not use condoms. “I’m not an idiot,” she says. “I know I can get pregnant but he did not want to use one…” Her voice trails off, and then she says, “Anyway, it doesn’t matter now. Di naman ako nabuntis, ‘di ba (I didn’t get pregnant, did I)?”

FAD’S PHONE-a-friend hotline is one of the few venues that young people can anonymously call and ask about questions about relationships and reproductive health. One hotline counselor there says that young people are likely to have many misconceptions and few facts. For example, she says, they will judge reproductive health on mere appearance. “They think if someone is beautiful or sexy and looks rich and clean, he or she is healthy,” the counselor says. “They say you can get STIs only from nightclub workers.”

Sometimes, she says, callers reason, “Kilala ko naman siya. ‘Di siya gano’n (I know the person. He/She is not like that.).” But it is precisely knowing their partner in the biblical sense, unarmed with the knowledge of the consequences, that gets these teens into trouble in the first place. Some other common misconceptions include drinking Coke to prevent STIs and jumping up and down steps to regulate the menstrual cycle. There are even those who believe one can’t get pregnant from one’s first sexual intercourse or if the woman’s on top.

Two of three respondents in the YAFS study said they know about STIs in general. Awareness of HIV/AIDS is near universal at 95 percent, yet only 27 percent think there is a chance of them getting AIDS. Also, the misconception that AIDS is curable has worsened from 12 percent in 1994 to 28 percent in 2002. Predictably, HIV/AIDS and STI awareness is higher in urban areas, among better-educated classes, and among older youth (20-24) vs. the younger (15-19), and those with more exposure to the media. The hotline counselor says that some teens are unfazed when they test positive for an STI. Adolescent males may even consider STIs to be “warrior marks,” proof of their sexual prowess. The first concern of younger callers — those 16 and below who consult the hotline because they suspect they have been infected — is not their own health but how they could win back their girlfriends or boyfriends. “They don’t see it’s a serious problem,” notes the counselor.

Indeed, they don’t. The YAFS study says only 80 percent of young people used contraception the first time they had sex. Unsurprisingly, 74 percent of all estimated illegitimate births are by 15-24 year olds. There are 400,000 cases of illegal abortions every year, and young women account for nearly four out of 10 cases of abortion complications.

WHO IS supposed to teach young people about sex? Some experts believe schools should. They say many parents lack the knowledge and may even be the ones perpetrating misconceptions. In addition, studies show young people do not talk to their parents about sex. Information from family is often limited to ideal gender roles and lectures about refraining from sexual activity. Most teens get their information from peers, movies, television shows, and books.

While the government has opened its doors to talking about adolescent health, it is unable to do this enough. There are NGOs that try to fill the gap but, as FAD’s Villa says, “we have limited reach.” The government, by comparison, “can be everywhere.”

Unfortunately, the government can also block information. Without a clear national population control program, local health workers are obliged to obey municipal officials who impose personal beliefs on state policy. With Mayor Lito Atienza’s staunch stance against artificial birth control, for example, the city of Manila has become a hostile place for NGOs. Clinics are discouraged from promoting family planning and safe sex and from distributing condoms.

Dr. Carolyn Sobritchea, director of the Center for Women’s Studies at the University of the Philippines, is aghast. “The right to reproductive health is a human right,” she says. “Governments must provide all the information for individuals to make the right decisions for themselves.” She adds, “I don’t look at it from a moral dimension. That’s not my place. As a teacher, I would like to imbue them with the knowledge and skills to protect themselves.”

She calms down the fears of officials who think that more knowledge about sex could lead to promiscuity. “It’s simply not true,” she says. “I can cite the statistics of Japan and other countries where you have condoms and pills in dormitories.”

Most health workers support sex education in schools although they unanimously stress that abstinence remains the best protection. But they reiterate that balanced teaching is key. Although information should never be withheld, it should be balanced with responsibility.

FAD, for one, has produced “STI Confidential,” an educational video with popular young star Judy Ann Santos as host. POGS launched two years ago an STD awareness program aimed at schools, starting from Grade 5 onwards. Some schools have also taken steps toward more informative and grounded discussions on sex. Incoming freshmen at the University of the Philippines now have to take a mandatory course on gender, sexuality, and culture. The class tackles issues such as STIs, unwanted pregnancies, boyfriend battering, and sexual abuse.

The likes of Sobritchea remain hopeful. “Young people today are very responsible,” the professor says. “They just need the proper information.”

Cheryl Chan is Chinese-Filipino and moved to Canada in her teens. She is currently completing a master’s degree in journalism at the University of British Columbia in Vancouver.