September 2006
Health and the Filipino

Stress and the Filipino

Sure, Filipinos are resilient, but this doesn’t necessarily mean we don’t feel stressed.

HOW DO we say we’re stressed in Filipino?

We don’t. Well, at least not in a way that we would in English: I am stressed. It just doesn’t work out; we don’t, as far as I know, have a word in any of our Philippine languages for stress and being stressed.

But that doesn’t mean we Filipinos don’t ever experience stress. We feel it all the time and we see it producing illnesses, both physical and mental, both fleeting (as in having to run to the toilet) and serious, life-threatening ones. Because stress affects the body’s immune system, we can say all ailments are in one way or another stress-related, from asthma to singaw (canker sores), to cardiovascular ailments and even infectious diseases.

There’s also a tendency to dismiss stress-related illnesses as “psychological,” and that these are self-limiting, easily resolved. The fact is that stress can so overwhelm people that they lapse into depression, resorting to destructive behavior, directed toward the self, or toward others.

The drug companies, especially those producing vitamins, have tried to cash in, pushing their products through advertisements showing stressed people and dangling promises: with our product, you can meet the many stresses of life, and of the world, and survive without falling ill. One vitamin has even gone to the extent of incorporating the word “stress” into its brand name.

But doctors — at least reputable ones — will tell you that medicines are of limited use for handling stress. Vitamins can help you to deal with the harmful chemicals produced in the body that come after stress, but as long as you don’t deal with the stress itself, you eventually lose out.

Besides the vitamin ads, the media bombard us with all kinds of articles about, and ads for, New Age therapies that supposedly help us deal with stress — to name a few, yoga and meditation, spas offering massage and aromatherapy, soothing music interspersed with sounds of birds and frogs. But these are often expensive fads with exaggerated claims.

Not enough’s being done to understanding stress in its local context, yet stress is mediated through culture: from the very nature of the stressors, to the ways we respond to the stress. Understanding this local context might help us develop more culturally appropriate, and therefore more effective, ways to deal with stress.

STRESSORS ARE not universal. For example, we say “noise” is stressful, but what exactly is noise?

Culturally, we have different thresholds for these sounds. I have a nephew and a niece who were born and bred in Canada, and they find the Philippines too “noisy”: the jeepneys, the arcade games in malls, even the way people talk. Yet they have no problems tuning into hard rock music on their iPods.

My nephew and niece also find crowds stressful; yet a Filipino sees a crowd and is delighted, “Uy, masaya.” Westerners crave privacy; the Filipino is stressed by solitude. We’re not alone, of course, in finding pleasure in crowds and camaraderie. Culture adapts to circumstances and we are only one of many countries with large dense populations that have learned to live with the maddening crowds, complete with the noise. The Chinese, for example, refer to “merriment” as re nao, the words for “hot” and “noisy.”

While we enjoy noise, we’re quite sensitive to olfactory assaults. Filipinos will claim some odors are so bad they cause a stomachache. We sniff everything, from food to lovers, and the smells we find good, we tend to indulge to an excess. No wonder aromatherapy’s taken off in the Philippines, as did those terrible car fresheners and deodorizers.

Beyond these sensory stresses, we Filipinos do face many sources of stress, around work and livelihood mainly. Farmers worry about drought and typhoons; urbanites go berserk with tyrannical bosses and vicious gossipy office-mates.

Rural or urban, we all face the stresses of family, perhaps more so than in Western countries. We like to say we are family-oriented, with relatives always on hand to help out. But the extended Filipino family can be stressful too, with all its obligations. Overseas workers have a particularly difficult time with all the expectations family members have back home. I’ve met Filipinos overseas, from Hong Kong domestic workers to physicians in the United States, who postpone returning home for years because they dread the jeepneyloads of relatives waiting for pasalubong (gifts).

But the balikbayan in California has the advantage of distance. The poor migrants who go from impoverished rural areas to work in big cities face even greater stress from family relations, who can easily contact their now “rich” urban cousins for a share of the pittance these earn in the city.

OH, BUT the Filipino is resilient, we keep hearing. I’ve been in urban shanties where 15 people share 15 square meters of living space and yes, on the surface, everyone seems happy. Chinese Asiaweek once had a cover story featuring Filipinos as the happiest people in the world, unfazed by the most difficult of circumstances. One photo had a group of men drinking away in the middle of knee-high floodwaters.

But the scenes of smiling and laughing Filipinos, singing and dancing (and drinking) away can be deceptive. Quite often, we deal with stress by trying to be “happy.” I put that in quotes because the Filipino term is masaya, which is really more of an externalized merriment. Masaya is social camaraderie, it’s making cheer and quite often we do it precisely because there have been unhappy events, stressful events. The best example is that of a death — our wakes are notorious for its merry-making, but that, precisely, is part of our stress-coping mechanism.

We have folk psychology, maybe even folk psychiatry, at work here, Filipinos aware of how dangerous it is to allow stress to consume us. We warn people about excesses as a cause of illness, and that includes the excessive emotions generated by stress. The word dalamhati is graphic, describing an inner sadness (from the Malay dalam, inside and hati, the heart or the liver, believed to be seats of our emotions) that slowly consumes the person.

But for all the talk about our communitarian orientation, of helping friends to overcome stress, social pressures in the Philippines can also be counterproductive with the way we sometimes force people to repress the stress. “Enjoy!” we urge them, not realizing there are limits to resilience.

There are power dimensions to all this, such as those found in gender. Contrary to stereotypes about women being more expressive, Filipinas are actually more prone to dealing with stressful situations through tiis (endurance) and kimkim (repression). Check out the local scenes of merriment: it’s usually men having a good time, bringing out the beer and toasting their problems away, while their women look for ways to make ends meet.

Men, too, are expected to keep their feelings in check, but more out of masculine values of strength and stoicism. Men are generally not allowed to cry, much less to go into hysterics; and this probably helps to explain why more men suffer from cardiovascular disease.

Many Filipinos will express their stress by complaining about recurring headaches, or abdominal pains, accompanied by dizziness, nausea, fatigue. Doctors used to dismiss these as being all in the mind, but it has become clear the physical pain and distress may be quite real, that the pent-up stress is expressed through the body.

These vague symptoms have been labeled as “somatization syndrome,” and are often hard to treat, partly because medical professionals still haven’t figured out the biological processes involved. Culturally, too, people may attach labels that don’t quite reflect the actual part of the body that’s affected, as when they say that they’re suffering from nerbyos or “nerves.” Nerbyos doesn’t necessarily mean being nervous; it’s often hypertension or high blood pressure, for example, and a health professional or caregiver may miss the problem.

Then, too, there’s the intriguing bangungot, those sudden deaths, usually at night, associated with nightmares. The term itself is derived from bangon, to rise, and ungol, to moan. Young healthy men, like the late actor Rico Yan, die mysteriously and the diagnosis is immediate: bangungot. The medical world remains stumped, attributing the deaths to everything, from pancreatitis to congenital defects in the heart, but too little has been done to explore the stress angle. Similar “culture-bound” illnesses are found also in other neighboring countries and the deaths tend to be reported in international medical journals because they often occur in people who are away from home. The first cases reported in U.S. medical literature involved Filipinos in the U.S. Navy. In recent years, medical reports have included Thai men doing construction work in Singapore, and Indochinese refugees who have just relocated to the United States.

I wouldn’t be surprised if bangungot is reported as well among our 8.5 million overseas Filipinos. The Filipino is so attached to home and hearth that we even have a term namamahay, missing home, to describe a range of symptoms, from insomnia to constipation that plagues us when we are away from home. That’s stress too. And with men, given the cultural imperative of suppressing their distress, we might expect nightmares, some with fatal endings.

ALL SAID, there’s a political economy of stress involved, meaning power relations shape the way one experiences and expresses stress. Common sense tells us the poor suffer much more daily stress, from battling the traffic while commuting, breathing in more of the toxic fumes, dealing with tyrannical bosses and snakepit offices. Poor women are doubly burdened, having to deal with the tribulations of work, as well as of the home, running after the needs of husband and children.

Public health analysts in Western countries have produced voluminous literature on how poverty interacts with stress to cause illnesses and death. Earlier research tended to be simplistic, explaining high illness and death rates among the poor as being due to their lack of access to good health care. But more recent research has shown that the problems of poverty also relate to power and autonomy. The poor are less healthy because they suffer more stress, not just from what I described earlier, but also from the inequities in power. The poor are more prone to feeling helpless and will have less self-esteem — all that contributes to a more rapid deterioration of health when confronted with stressors.

Men may be more prone to the problem of this “political economy of stress,” since they have to live up to higher expectations of gender. A jobless man, for example, may be more adversely affected by stress because of a loss of pride. Machismo also blocks him from taking up jobs that he thinks are beneath his station. So he ends up drinking with the barkada, which is then interpreted as “resilience” and an ability to be happy. His wife, meanwhile, will pick up odd jobs here and there, doing laundry, mending clothes; ironically, that again generates stress for him, as he feels his masculinity threatened.

The macho imperatives around stress are inevitably tied to alcohol and drugs. Younger male Filipinos are particularly vulnerable, given their struggles with identity, masculinity and self-esteem, unable to express their frustrations and resentment. Drugs are one way of dealing with the stress, with all its attendant problems. It’s significant though that the most abused drugs are metaphetamines, which are “uppers” or stimulants. Again, the Filipino response to stress is to look for more stimulation. The nerve cells fire away until, frayed and exhausted, the user develops paranoia (borrowed into Filipino as praning) and then psychosis.

Others take out their frustrations through violent behavior. The phenomenon of the amok, favorite fare for our tabloid newspapers, used to be the subject of racialized descriptions from Western anthropologists, who thought that those belonging to the “Malay race,” including Filipinos, were especially prone to going on a violent rampage, sometimes with hostage-taking.

The racial angle is total nonsense of course. Running amok has nothing to do with race. It’s, quite simply, a person reaching the end of the line, or put another way, the bottom of the heap. It’s the poorest, most disempowered men, who tend to run amok. A stressed rich man takes out his frustrations on those lower in a pecking order; the amok has no one, not even the dogs at home, to vent his anger, so he turns to random violence.

ALL THAT discussion should have stressed you by now, and made you wonder: given the deteriorating economic and political situation in the Philippines, are we about to see an epidemic of stress-related ailments?

I think we’re already in that epidemic, and too little is being done to help Filipinos tackle stress.

I’ve intentionally used the verb “tackle” rather than “treat” because there is a tendency to medicalize stress, to look for drug treatments that could lead to new dependencies. The drug companies push all kinds of “antidepressants” to doctors, who are then quick to prescribe them to stressed patients.

Sessions with psychiatrists or psychologists are more effective than drug treatments, but again, low incomes may prevent many Filipinos from getting the “talking therapy” they need. That is why we need to be able to tap what we already have in culture, looking into how families and communities can be mobilized to help people with their stress.

I feel community health workers are under-utilized for mental health. Given some training, they can learn to help their barangay residents with stress. That includes essentials about counseling, for example, not resorting to that notorious sulsol (“Oh yes, your husband is really terrible, and mare, you know I just didn’t want to tell you but we’ve all known all this time that. . .”)

In the United States, studies are showing that somatization syndrome is best handled with what’s called cognitive restructuring, helping patients to take on new lenses as they revisit their problems. Instead of wallowing in self-pity as a victim, cognitive restructuring helps people regain some sense of control.

We have that in our folk therapies — note how, in bangungot, we’re supposed to try to move a finger, a toe, any part of the body. It’s not a symbolic act; it actually means taking control of one’s own body, and the failing spirit. It’s a powerful metaphor that can be used to explain other stress-related ailments and syndromes.

I’m ambivalent about New Age therapies such as meditation and aromatherapy, but mainly because the type offered by spas and health resorts are just totally inappropriate. Since we’re a very olfactory people, I think there is a place for aromatherapy. Sadly, we’re importing expensive aromatic oils when there are local plants that can be used; in fact, some of the most expensive aromatic oils are extracted from local plants we take for granted, like ylang-ylang.

But I do see a place for many traditional therapies being rechanneled toward stress management. The manghihilot can be “reinvented” so his or her skills with therapeutic massage can be applied not just for sprains, but also for broken hearts and weary spirits.

Massage and aromatherapy, however, are only the externals. Stress management is really helping people to dissect their own feelings, to understand where their distress is coming from. The solutions may not always be easy — all the aromatherapy and meditation in the world will not raise low wages.

But community action can help to make the stress more tolerable. Communities should be urged to create their own safe spaces where people can seek some refuge. Filipino-style, such spaces need not be totally quiet, but they do need to give some sense of safety, of sanity in a mad world. Filipino-style, too, we need to think of how these therapeutic spaces might work out as places where people can engage in social activities, without becoming more agitated. Alternatives could be offered: gardening, cross-stitching, bingo…anything that calms the mind. You don’t need to be in the lotus position to meditate.

Ultimately, stress management is a matter of helping people to recognize that the world, which seems so stressful, can also be a source of joy and pleasure, fulfillment and renewal. The therapies being dangled around are really meant as appetizers, ways of inducing the depressed the person to garner enough strength and courage to re-engage not just the world, but life itself.

Michael L. Tan is a medical anthropologist. He is currently chair of the anthropology at UP Diliman, Quezon City. He also writes an op-ed column, “Pinoy Kasi,” for the Philippine Daily Inquirer.