The Apothecary Romanticism
How Physicians in far flung areas appear magical
Without scientific papers and without conventions and knowledge sharing, science reverts into magic. The moment magicians and wizards start periodically writing down and comparing their tomes, grimoires, and secrets en masse; is the moment clarity and cited understanding occurs. It is the moment magic turns into science.
From ancient times up until the late renaissance, the medicine man — much like other erudite professions of the time — was a skill passed on from master to apprentice. Often singular rather than plural. Because of this, the skill or knowledge of healing has a wide variety. Healer, priest, druid, apothecary, chirurgeon, herbalist. Differing flavors with the same final objective.
After finishing their instruction with their masters, these medicine men would go out on their own. What notes they accumulated later taking form as tomes that overtime will be sacred. They will then collect parts of flora and fauna to be later processed into tinctures, infusions, or potions for healing. Some would also infuse rituals to their practices connected to their religion or beliefs. Their skill of the above determines their effectiveness.
In both cities and rural provinces, the majority of people have no education save from skills and knowledge they learn from their parents. Public health was nonexistent unless if you’d consider rudimentary sanitation structures. Hence, apothecaries regardless of where they choose to practice, will appear to be extremely knowledgeable and wise. A particularly skilled one, being able to produce potent concoctions and treatments, can appear magical. It does not matter if one knows a treatment exists, if he does not have the ingredients or materials in his arsenal, the lay person would consider him a poor doctor. In contrast, a healer that stumbles upon a new cure or just luckily have a patient that defeats their disease with their own constitution — can easily be called a “miracle worker”.
Being “wizards” in a sense, and unlike in modern times — there is no governing body to police their actions or tell them what they could or could not do. Apothecaries are free to expand their knowledge via haphazard trial and error. A failed concoction, or an accidental poisoning, or a misunderstood physical treatment is chalked off as “Will of God”, rather than “Medical Malpractice”. Though it is also the only way to expand medicine until the advent of the “Scientific Method”, where more controlled and more humane tests decreased the haphazard nature of ancient medicine.
Accomplished medicine men, with the arrival of education and writing, would eventually compile their knowledge in personal books and journals. This will be passed down to their protégés, or end up in libraries to be copied by curious doctors. Here they can start comparing notes, seeing what works and what doesn’t. Practitioners begin to be associated as “students of this person/master”.
As time goes on, medicine men would form societies in order to facilitate sharing of knowledge. This would allow them to push the boundaries of medicine as compared to solitary doctors redundantly having to rediscover knowledge known already by others. The process hastens with the creation of universities that teach “medicine”. With a greater body of accumulated texts and teachings, university doctors have the privilege of comparing and testing theories out further. The ultimate improvement being the “Scientific Method”, which allows doctors to debunk and confirm the various practices with the use of statistics.
Modern medicine is thus born, basing on prior understandings and solidified by scientific tests — a clear collection of what works and what doesn’t materializes. With a notion of right and wrong, medical practice can now be policed. Governing bodies arise and a definition of “Good practice” and “Malpractice” ensures the spread of quality medicine. Universities produce more practitioners. “Students of this master”, turn into “Students of this university”. Medicine at its basic level, starts to lose its magic.
With the expanding body of knowledge comes division of expertise. Potion making has been deferred to the art of Pharmacy and Chemistry, the creation and study of refined medications. To ease the burden for doctors, it would no longer be necessary to have them master medicine making, and focus instead on diagnosing and treating based on established guidelines. Guidelines are created basing on studies and tests, serving as an easy protocol for doctors to follow. Further standardizing treatment.
Deeper and expansive understandings amongst the budding fields produce medical specialties and subspecialties such as Surgery, Pediatrics, Obstetrics, etc.
This man suffered a motorcycle accident incurring a wide gash along the chest exposing his ribs. We could see his beating heart. He was poor, it was the dead of night, the nearest hospital was 6 hours boat ride away. He was brought into my small infirmary, and my two nurses were aghast at what to do. I told them we had no choice but to just keep stitching, and we closed the wound layer by layer. -Dr. Arthur Tansiongco, General Practitioner
The romanticizing of apothecaries as mythical miracle workers was borne from their rarity and the poor education levels at the time. I term it as the Apothecary Complex, and while it has largely gone away as the world modernized, there are still some last vestiges. The university-trained medical doctors often tend to cling to cities and clusters of civilization. Those who do decide to venture out to far flung and more rural areas tend to maintain and experience the Apothecary complex.
While they no longer possess the art of medicine making, they must see to it to purchase and bring their own stock of medicines — as the places they’re going to lack pharmacies. They must bring their own surgical and diagnostic tools if need be — as it is presumed there is a scarcity of doctors and specialists where they are going to. Hence to the rural inhabitants, he is a source of mythical treatment.
In a way, there is a sense of “pioneering” spirit amongst the first university-trained physicians that venture out into far flung areas. The have a knowledge of the best practice available but since the places they are going to lack the needed facilities, they have to make do with older or less ideal strategies.
Take for example, child birth: modern medicine expounds the necessity of a labor room, ready emergency and surgical tools, and a pediatrician and obstetrician working together. It ensures maximum newborn and mother survival and safety. It is a step up from Midwives. However, lacking, such facilities, the doctor would assume the same management as that of midwives, that slightly increases risk. Which in itself is a step up from unclean and very risky unsupported home birth. It’s “good enough” and considered better than nothing to the denizens of far flung and impoverished areas.
Another example concerns the use of diagnostics. Modern medicine would have doctors consider using diagnostic tests such as xrays and blood tests if their post examination diagnosis is unsure or not clear cut. Without ready access to diagnostic machines, a doctor would have difficulty delineating between diagnoses. So instead of referring them towards the city which means paying for transportation and lodging, which the patient could ill afford — the doctor instead resorts to what is termed shotgun therapy. Wherein they will both employ the treatments for all considered diagnoses. This means instead of using 1–2 medications, the doctor will prescribe 3–6 in the hopes of hitting upon the cause of the disease. And while considered a weak form of malpractice, because of being cheaper than the alternative of traveling, the doctor is often lauded. Lay people would consider a doctor good, if they immediately prescribe multiple medications on their first visit — not knowing any better if the doctor is employing shotgun therapy. On the flip side, a doctor that strictly follows guidelines and requests the patient to travel for diagnostics is frowned upon by lay people.
A third example is with involuntary palliation. Discovering patients with advanced chronic diseases like heart failure, chronic obstructive pulmonary disease, or advanced cancer — doctors under the assumption that the patient could not afford expensive city treatment, resorts to just treating the symptoms instead of the root cause. They could either tell them the harsh truth, or spare them the worry. They would treat the pain, difficulty of breathing, and attempt to at least give what bit of functionality the patient could get. All while the patient’s main disease worsens inside. Doctors who simply say they could do nothing and state that the patient must see a specialist in a far away city is seen as a weak doctor. While those doctors who go straight away and just alleviate the symptoms without treating the root cause are seen as good doctors. This is regardless if they make the patient aware of the root cause or not. Of course, more educated patients would be dubious of such actions. But they are either rare in rural impoverished areas, or don’t have much choice.
The island used to have a hospital where surgeries such as appendectomies and caesarean sections were done. But lately the regional DOH head has deemed the hospital inadequate and downgraded it to an infirmary. No more surgeries. The lay folk don’t know that, and they are continuously dismayed that emergency cases brought to the hospital are often “referred” to the next island. Or that severe trauma often meant death. This eventually created the misconception that the sole “hospital” in the island, was a bad one. -A local situation in a MIMAROPA island
The apothecary complex exists not because of any backwardness of Medicine, but because of the lack of access to health care. The reasons of this lack include 1) Doctors preferring to practice in cities, 2) Financial difficulties of patients, 3) Poor or nonexistent health facilities.
In the Philippines, patients prioritize seeing specialists first instead of general practitioners. This might come from a history of GPs having a poor track record which in itself can be indicative of inadequate training system that only gets fully fleshed out when said doctor enters further training in specialist residency programs. Parents of medical students would always push them to get residency training.
Specialists will often be tied down in cities however; as either the equipment they need are only available there, and/or the consultation fees can only be afforded by city folk. There are exceptions to this, which include adventurous and idealistic physicians, to the offsprings of rural folk whom are privileged and promised to return after educating themselves. These are few and far between. The trend still points to the unbalanced distribution of skilled physicians to the cities.
And even if a location is lucky enough to have a specialist, the majority could ill afford his/her services or the medications and equipment may not be readily available or justifiable to put. In a way the current system of general practitioners and primary care physicians being spread out throughout the country while the specialists are concentrated on cities do make sense. As most that could afford specialists are in the cities, and the population density of cities justify the concentrated placing of specialists. The generalists from far flung areas will refer any complicated cases towards the cities. Contemporary trainings teach new doctors to rely on referral networks and not trying to solve everything on their own. This has a merit of giving patients specific and maximum care. What is not being expounded upon is if the patient has no financial capacity to afford specialists and stay in the city.
This new method of training a “team based” approach aims to maximize manpower resources. The numerous GPs treating basic diseases while promptly referring more complicated cases to specialists clustered in cities. This is also an organic adaptation to the limited health facilities, manpower, and government budgeting in rural provinces.
This is sound in an organizational standpoint, but the reality is different when you factor in the patient’s capacity to pay and their easy accessibility to the cities. This accessibility problem is exacerbated by the archipelagic nature of the country. This is exemplified by the MIMAROPA or Mindanao regions of the country. In a continental country, a trip to the specialist means roughly a 100–200 pesos bus ride and a return trip within the day or on the next day, with patients just waiting or sleeping by the bus terminal. In an archipelagic province, a trip to the specialist hospital means 500–1000 pesos ship ride, additional vehicular rides of 50–200 pesos, and one has to worry about lodgings averaging 500 pesos a night, since the ship only arrives on certain schedules once a day. This amounts to about 1600–3600 pesos in traveling and lodgings alone! This does not bode well for the average poor class Filipino with incomes of 50–300 pesos a day.
The accessibility problem has two effects. First, it enforces the Filipino’s inherent trait of suffering through the disease and hope for their own constitution to take care of it or wait until it gets really severe, and often more costly to treat before seeking consult. Secondly, it contributes to the preference for the Apothecary Complex. This is where the Team Based method clashes with the Apothecary Complex. From an academic standpoint, the team-based method sort of downplays the GP’s self-worth and ability. They lose their confidence in treating emergency cases and complicated cases as contemporary guidelines hammer into them the importance of diagnostics and referral to specialists. Hence it is a mixed bag whether a newly graduated GP is drilled into the method or has adventurous tendencies. If he/she is of the former, they might shy away from testing out obsolete — but “good enough” treatments for patients who couldn’t afford traveling to specialists. Oftentimes, these method based GPs are quick to refer cases without consulting the patient’s capacity to pay.
With a failure to comply to the referral order, the patient would often be lost to follow up with the doctor, untreated or worse. Sometimes a patient can admit to their financial difficulties. But the GP, being too strict on guidelines or afraid of litigations from malpractice says they couldn’t treat them. If instead the GP has a pioneering and adventurous spirit, and a better grasp of physiology and pathology, they could attempt using alternative approaches or more obsolete techniques to treat the patient.
The Apothecary Complex isn’t just with doctors alone, but can also be applied to bigger organizations of health care such as the Rural Health Unit (RHU) or Barangay Health Centers. In the city, they have the luxury of a proper referral system. Laboratories are easily available; hospitals and specialists are within reach. It is the right call for City Health Centers to refer patients when the need arises. In the case of Rural Health Centers however, especially ones in the island provinces — the referral system is marred by travel expenses and travel time. If an RHU assumes the same proclivities as their equivalents in the cities, it will lead to disappointed patients that could ill-afford the referral and end up being lost to follow up, their diseases possibly worsening. Secondly, multiple RHUs can overload a single regional hospital which in themselves are often understaffed.
Suppose an RHU, as a compromise, assume a form of Apothecary Complex, using “good enough” strategies instead of going for maximum gold standard strategies. Trying to work with the patient’s financial capabilities in mind, they can set about finding an alternative “good enough” solutions. For example: dehydrated patients from diarrhea or vomiting, can easily be given IV fluids and monitored for 6–10 hours in the health center instead of being sent to the hospital. Instead of being reluctant to stock up on Epinephrine or Hydrocortisone vials for use in anaphylactic shocks, the health center can stock up and decrease the risk of delay borne about from travel time. Skin abscesses that have to be sent to a hospital to get a clean operating area, can make do with judicious sterile techniques practiced by the doctor and proper use of antibiotics — which are all possible in the health center. Skin ulcers that have to be referred to hospital admissions for daily cleaning, can also be treated by properly teaching patients and patient relatives of the use of Daikin’s solution (a form of homemade antiseptic). This will have the added effect of decreasing the burden of Hospitals, and ensuring the time and energy of the outnumbered staff can be best put to use.
This is not to say that all cases be withheld from referral. There will be cases that are far beyond the capabilities of an unequipped facility — gold standard or otherwise. These include stroke and heart attack cases. The travel times to specialty centers will almost always be beyond that of the “golden period” required to rescue functionality — at the very least the frontline doctors, health centers, and hospitals can stabilize and ensure the situation doesn’t get worse.
While city health centers and institutions can afford to be reactive. Rural Health Units cannot. They cannot wait idly until diseases become their worst forms at which case the RHU is ill equipped to handle. They must be proactive. Through education and proper patient relations, they fortify the health of the population they’re responsible for. Instead of waiting for hypertension to turn into stroke or heart attack, or for diabetes to destroy the kidneys or poison the blood — they can teach the importance of taking maintenance medication and healthy lifestyle changes.
The end of the essay, is a callout to the institutions out there. That a form of Apothecary Complex is necessary in the current economy and in the archipelagic nature of the country. That medical schools focus on training their students into Generalist Physicians, instead of just being a preparatory for Specialty Training Programs. Admittedly, the former seems to be a current trend this decade. That DOH can adjust their stringent requirements to allow some degree of freedom for their subordinate units to adjust to their current geographic, economic, and political situations. That future physicians be trained to be mindful of the financial, travel, and mental capabilities of their patients. This is already being slowly introduced as “Biopsychosocial Approach” in some medical schools. It is ideal that everyone get the best and current medical treatment borne from centuries of science, but in the frontiers of society, our healthcare workers need to do some magic.
This essay was originally written during the pre-pandemic era, 25 Nov 2019.