Uncharitable wards

"Got newspapers?" the nurse asks, rather sternly.
"Newspaper? What newspaper, Ma’am?" the shivering patient asks in return, rather confused. "None, Ma’am. What for, Ma’am?"

"Next time you come here bleeding like that, be sure to bring newspapers. We don’t want our table to be smeared with blood."

The dialogue above, between a caustic-talking night-shift nurse and a beleaguered woman seeking help at a government hospital after an abortion, is the stuff of local theater.

It is part of a tragic-comic monologue dubbed Uwag (Desire), written by the prize-winning playwright Lualhati Bautista on the travails of EveryPinay.

It has been used recently by the CreativeCollectiveCenter, Inc. as an interactive forum-theater tool to discuss and debate issues of reproductive health rights in schools and communities. It is packaged as a component of the traveling exhibit, “Who Owns Women’s Bodies?”

But new research here reveals that the harsh realities poor womenfolk must face in government-administered charity wards are akin to the pathos of Bautista’s dramatic fiction.

Medical staff, particularly nurses, who are also women, are rather harsh on women patients, Magdalena Cabaraban and Maria Theresa Sharon Linog of the Research Institute for Mindanao Culture (RimCu) conclude in their recent study on the experiences of patients in charity wards.

The mother-daughter duo studied extensively at least 50 cases of patients at the charity wards for women at the Northern Mindanao Regional Training Hospital and the Borja Memorial City Hospital last year.

In charity wards, medical services and bed spaces are free but patients have to buy their own medicines.

The research includes the startling revelation that the women patients said it is "normal" to allow themselves to be scolded, insulted, shouted at and treated harshly. They thought they ought to be treated that way; and most of them felt powerless to correct the bad treatment.

"The painful thing is that: this is what they thought what ‘charity’ means. Maybe they were a bit sarcastic when they said that during a focus group discussion. But we did hear it often.

For example, we kept on hearing this from our subjects: ‘charity means scolding and ridicule because we are poor’, " said Cabaraban.

"A poor woman like me who does not have money cannot hope to get nice treatment in a hospital," echoed the self-deprecating woman in the Uwag monologue.

The medical staff particularly discriminates against women who have forced abortions, says the Cabaraban-Linog study called, "Uncovering the Experiences of Patients in Charity Cases: Ethical and Legal Implications ".

To cope with the ill treatment, other women told of dissociating themselves from the experience and letting the words flow from one ear to another and out into empty space. A few recalled striking back by trading insults with the attending nurses. Others simply fell silent, accepting—and perhaps implicitly agreeing with--the harsh treatment.

Still for others, dark humor as in the monologue, worked: "If I take it to heart, I will have more problems from a heart attack aside from a bleeding vagina," said one such woman who hadn’t lost her funny bone despite her despair.

The State of the Philippine Population Report 2000 estimates that there are about 300,000 to 500,000 abortions in the country today. The estimate was based on the number of women reported to have been admitted to hospitals for the treatment of medical complications following an abortion. This translates into a national rate of about 25 abortions per 1000 women aged 15-44 each year.

Abortion remains illegal in the Philippines, a country with a predominantly Roman Catholic population. The Revised Penal Code considers abortion a crime tantamount to murder, and carries the penalty of maximum imprisonment of 12 to 20 years.

The World Health Organization (WHO) estimates that at least 80,000 maternal deaths (approximately 13 percent, or one in eight of all maternal deaths) each year are caused by unsafe abortions.

Thousands more women experience complications due to unsafe abortions and suffer from crippling injuries, chronic pain or infertility. Most of these deaths and complications could have been prevented if the women had access to post-abortion care.

Post-abortion care includes emergency treatment of complications, post-abortion family planning counseling, referral and links to other reproductive health-related services.

The country’s Department of Health already has a program called Prevention and Management of Abortion Cases and Complications (PMAC) as described in an administrative order issued in 2000. But two years later, the program still awaits full implementation at health-delivery sites such as the two hospitals in the study. The perennial lack of budget to pay trained staff has been cited as the reason why the PMAC program can’t be implemented fully yet.

Moreover, speaking at a forum after the Uwag monologue, Cabaraban also revealed that the women she and her daughter surveyed also cannot distinguish between "rights" and "responsibilities". The reason could be linguistic and cultural. The Filipino traditional culture emphasizes a woman’s responsibilities towards family rather than the assertion of her own rights as a human being.

In the Bisayan language, the major dialect used in the island, the word for 'right', katungod, is not only used interchangeably with katungdanan, the word for 'responsibility'. It also appears that among the women who were part of the study, there is a blurring of distinction of meaning between the two words, with the burdens of responsibility taking heavier weight over inherent human rights.
A large majority of the patients interviewed for the research study, 44 out of 50, considered as their major "right" (the responsibility) to serve and care for the husband and children, to manage the household, to prepare food, discipline the children and help earn the family bread.

Only about five percent of the women involved in the study knew and understood their reproductive health rights. These are the same women who can distinguish between rights and responsibilities. They are also at least high school graduates who got one form of training from non-government organizations.

Cabaraban, a senior research fellow at the Research Institute for Mindanao Cultures (Rimcu) perceived this as a reflection of deeply ingrained cultural attitudes regarding women’s roles and responsibilities.

"We are up against centuries of cultural conditioning, particularly those of the Roman Catholic upbringing, which puts value on self-sacrifice, especially for women, as a requirement for sainthood. It is also the same mindset that views abortion as morally wrong and sinful," she added. These women were brought up that being a good woman means being responsible for others, never for herself.

Cabaraban and Linog also interviewed the nurses, some of whom pleaded guilty to having treated the patients harshly. They said their attitude is also a coping mechanism for the heavy workload, long work hours but underpaid conditions they have to face every day.

The study recommended some basic changes so the public hospital charity ward system can cope effectively with the growing need for post-abortion care in particular and women’s reproductive health rights in general. But the changes do not have much to do with the design of hospitals to allow for bigger space for wards, since the researchers are aware that these institutions "have to grapple with a lot of constraints and scarce resources."

What is possible, said the study, is engineering changes in social attitudes among the urban poor womenfolk and the service providers, including doctors, nurses and midwives.

They also suggested training the thousands of barangay health workers, which serve as the backbone of the country’s health system in the grassroots, to become trainors of barangay women on charity health care and reproductive health rights.

Meanwhile, like the nurses, a midwife who attended the interactive forum on reproductive health rights after the monologue, turned confessional. She shared how shocked she was to see and hear the performance of Uwag.

"The dialogue was very familiar. I used to hear it. Then, I realized what was most familiar was the sarcastic tone, the anger. I remembered I said the same words somehow, sometime to someone."

In the tearjerker Uwag, the woman felt like "a slab of meat in a slaughterhouse" as the doctor turned her bleeding body parts into a specimen for a medical class.
Can’t distinguish between rights and responsibilities

Moreover, speaking at a forum after the Uwag monologue, Cabaraban also revealed that the women she and her daughter surveyed also cannot distinguish between "rights" and "responsibilities". The reason could be linguistic and cultural. The Filipino traditional culture emphasizes a woman’s responsibilities towards family rather than the assertion of her own rights as a human being.

In Bisayan, the major dialect used in the island, the word for “right”, katungod, is not only used interchangeably with katungdanan, the word for responsibility.

It also appears that among the women who were part of the study, there is a blurring of distinction of meaning between the two words, with the burdens of responsibility taking heavier weight over inherent human rights.

A large majority of the patients interviewed for the research study, 44 out of 50, considered as their major "right" (the responsibility) to serve and care for the husband and children, to manage the household, to prepare food, discipline the children and help earn the family bread.

Only about five percent of the women involved in the study knew and understood their reproductive health rights. These are the same women who can distinguish between rights and responsibilities. They are also at least high school graduates who got one form of training from non-government organizations.

Cabaraban, a senior research fellow at the Research Institute for Mindanao Cultures (Rimcu) perceived this as a reflection of deeply ingrained cultural attitudes regarding women’s roles and responsibilities.

"We are up against centuries of cultural conditioning, particularly those of the Roman Catholic upbringing, which puts value on self-sacrifice, especially for women, as a requirement for sainthood. It is also the same mindset that views abortion as morally wrong and sinful," she added. These women were brought up that being a good woman means being responsible for others, never for herself.

Cabaraban and Linog also interviewed the nurses, some of whom pleaded guilty to having treated the patients harshly. They said their attitude is also a coping mechanism for the heavy workload, long work hours but underpaid conditions they have to face every day.

The study recommended some basic changes so the public hospital charity ward system can cope effectively with the growing need for post-abortion care in particular and women’s reproductive health rights in general. But the changes do not have much to do with the design of hospitals to allow for bigger space for wards, since the researchers are aware that these institutions "have to grapple with a lot of constraints and scarce resources."

What is possible, said the study, is engineering changes in social attitudes among the urban poor womenfolk and the service providers, including doctors, nurses and midwives.

They also suggested training the thousands of barangay health workers, which serve as the backbone of the country’s health system in the grassroots, to become trainors of barangay women on charity health care and reproductive health rights.

Meanwhile, like the nurses, a midwife who attended the interactive forum on reproductive health rights after the monologue, turned confessional. She shared how shocked she was to see and hear the performance of Uwag.

"The dialogue was very familiar. I used to hear it,” she said. “Then, suddenly I realized what was most familiar was the sarcastic tone, the anger. I remembered I said the same words somehow, sometime to someone.”