Buluan Lake: Through an Outsider's Eyes

Yesterday, my friend and I set out on a long drive in search of a scenic adventure in Buluan, Maguindanao del Sur. We imagined sweeping views of the lake, evoking similar images to Taal or Lake Sebu. From General Santos City we drove to Tacurong, crossed into Maguindanao del Sur, and entered its capital town of Buluan, the home to the vast and storied Buluan Lake.

Crossing the Buluan River bridge, we were struck by the unexpected sight of a promenade on both sides: red-bricked walkways lined with colorful buntings and banners, a mosque rising beside it, lending the place a quaint, almost picturesque provincial charm. Curious to find the best view of the lake, we asked around town. Vendors along the highway sold bundles of dried tilapia, a quiet reminder of the lake’s bounty. An old woman kindly pointed us down a cemented road that, she said, would lead us to the lake and on toward the “Landing Fish” -- a port we assumed to be the hub where fisherfolk brought in their daily tilapia catch.

For several minutes, we followed the narrow cemented road, which looked as though it had only recently been laid. On both sides stretched what we first thought were lush rice fields, their greenery half-submerged in shallow water that shimmered under the sun. It wasn’t until we began to see the familiar sight of tilapia spread out to dry that we realized we had, in fact, reached the lake itself. What we had mistaken for paddies were not rice fields at all, but thick growths of aquatic weeds thriving in the fertile waters of Buluan Lake, the third largest lake in Mindanao.

After a few hundred meters, we reached a small settlement. On both sides of the road stood shanties and the occasional sari-sari store, their stilts and walls half-submerged in knee-deep water. The lake had crept into daily life, blurring the boundary between land and shore. Soon, even the highway itself disappeared beneath the lake’s surface. We hesitated at first, uncertain if the road ahead was still safe. But then a few tricycles rattled past us, followed by a multi-cab and even a battered pick-up truck, all forging ahead without pause. Taking courage from them, we pressed on too, equal parts anxious and exhilarated by what might lie further down this watery road.

So we drove further on, slowly and cautiously. Along the way, we saw children splashing in the floodwaters, laughing as they bathed; adults soaping themselves and rinsing off with a tabo; old men brushing their teeth; women cleaning fish. All in the same water that lapped at their homes. As doctors, my friend and I couldn’t help but wonder about the illnesses that must quietly thrive in this place.

The flood bore all the signs of permanence. People had already adapted: narrow stilt bridges connected doorsteps to the road, and wooden canoes were moored outside houses like everyday vehicles. On the walls, faint lines marked past water levels, reminders of the ebb and swell of a lake that refused to recede. In some places, clusters of bright pink snail eggs clung to concrete walls, adding an almost delicate splash of color to the gray watermark of endurance. In between half-submerged shanties, lotuses drift calmly on the water -- a quiet proof that this flood is no longer a passing disaster, but a long-term way of life. But even in these images of despair, we caught sight of hope. A videoke machine stood proudly outside a sari-sari store, perched high on a sturdy table above the waterline. On the concrete wall of another store, this one selling vegetables and fish, hung a small box with a coin slot, which we assumed was for piso Wi-Fi.

Slowly, we inched along the submerged road, mindful of the car’s wheels, worried it might slip off the concrete shoulder, more worried still that we might hit one of the toddlers swimming freely in the water. It was Friday, 11 a.m., the sun already high, yet the whole community’s children seemed to be out there, splashing and laughing, with some floating in styrofoam boxes they had turned into makeshift boats. Many of them were completely naked, their faces smeared with mud, their bellies sticking out, conjuring images of Ascaris and hookworms. And yet they were happy, oblivious to the dangers of the flood that felt like a playground to them. The same waters that gave them so much joy might also bring the disease that could one day kill them. For a moment, it almost looked like play, until the question pressed itself on us: why were they here, in the floodwaters, instead of in school?

A few hundred meters further, our question was answered. On the right side of the road stood the community elementary school, submerged in mud and flood, its walls rotting, its corrugated green DepEd roof sagging in perpetual disrepair. It loomed like a haunted building, silent except for the distant shrieks of children swimming far away. Inside, there was no floor to be seen, only water, and not a soul in sight.

The flood had not spared the rest of the community’s lifelines. The mosques were submerged too, along with the government daycare center and the madrasa. Faded Arabic words still clung to the walls, faint reminders of the faith and learning these places once sheltered, before the deluge came and stayed.

Further ahead, a group of children, mostly girls, paddled cheerfully on a dugout canoe that had drifted across the road and blocked our way. Two of them balanced on its narrow edge, then leapt into the flood with shrieks of laughter, sending up great splashes as if the water were a playground. Their joy seemed unshaken, even though just a few meters away an old man, draped in a malong, squatted by the water, likely relieving his bowels into the same lake that both sustained and entrapped them, the same waters that had come to define their lives.

Up ahead, the road blurred into haze. We could no longer trace its outline; the horizon stretched before us, and it all seemed to be water. Slowly, we inched closer to the laughing children. Realizing we meant to pass, they pushed their canoe aside, clearing the way.

I rolled down my window, smiled, and asked, “Naa pa bay dalan? Pwede pa mi mo derecho?” The girls smiled shyly. One of the older ones hesitated, then gathered the courage to answer: “Derecho lang. Kaya lang man sa sakyanan.” She broke into a wide grin, revealing broken teeth, a smile as bright and fragile as the waters that had swallowed the road.

As soon as I rolled the car window down, a strange smell drifted in. We both caught it at once. It was the scent of decay, disease, and death. The same death we used to breathe in the ER and wards of PGH when we were trainees years ago. It was a heavy mix: the stench of rotten fish, soggy wood, human sweat, and bodies unwashed for days. I glanced at my friend; no words were needed. He knew. I thanked the girl softly, then closed the window.

We moved forward, inch by inch. A few hundred meters later, the houses and buildings grew fewer, until they seemed to vanish altogether. A quiet dread crept in. The road felt lonelier, unsafe. I opened the window again. The same odor floated back, but this time I realized it was not the scent of the children. It was the scent of the lake itself.

I was too afraid to turn back, so I clung to the girl’s assurance that the “Fish Landing” was still ahead, and no harm would come to us if we kept going, careful not to slip off the narrow road. So we pressed on, inch by inch, my hands tight on the wheel. My friend, sensing my unease, finally broke the silence: maybe we had already seen enough.

A few meters ahead, beside a small mosque, stood a concrete house. In front of it was a pick-up truck, its wheels sunk halfway into the water. To me it looked like salvation, a shallow spot where we could make a U-turn. Slowly, cautiously, I steered us around. Relief flooded in as we faced the way back.

We continued our drive back, our senses battered again by the same scenes we had passed earlier. My friend occasionally raised his phone to take photos, mostly of the place, never of the people. To capture their faces felt like a sin. It would have been poverty turned into spectacle, their lives reduced to images for our own consumption.

In that moment, we realized we were intruders: unwelcome outsiders peering into lives already burdened, as if they were specimens on display. To frame their hardship for our own record would have been an act of quiet cruelty. And so we chose to remember, not to capture.

We drove back in silence, each lost in thought. The scenes we passed were the same: the rhythms of daily life unfolding along the flooded road. Simple, ordinary acts: cooking, bathing, washing, waiting. Women gossiping. An old woman with a malong wrapped around her sagging body, peeling corn. And yet to us, they felt like an onslaught, not because of what people were doing, but because of the stark poverty in which they were forced to do it.

These were ordinary lives in an extraordinary setting. A setting so poor, so stripped down, that the mundane itself became almost nefarious, like a quiet indictment of a world that allowed it to persist.

Up ahead, the road stretched on, and we began to notice the water receding. Patches of dry land appeared here and there, breaking the monotony of the flood. On some segments of the concrete road, tilapia lay drying under the sun -- a quiet sign that we had finally left the waters behind. A sign that, at least for us, we had departed hell.

“Are you still up for some hiking? I don’t think I have the energy anymore,” my friend said somberly.

“Me too. Should we still see the rest of Maguindanao del Sur?” I asked.

He shook his head. “I think we’ve had enough for today. It’s hard to process what we just saw.”

On our way back to Koronadal, we crossed the Buluan River Bridge once more. The promenade greeted us again: red-bricked walkways, colorful buntings, fluttering banners. But this time it felt different. We realized it was all part of a vast machinery of deception, a way to cover up deep misery with superficial images of beauty and peace.

From my rearview mirror, I looked back at the lake, at the lives afloat in its waters. Why were they even allowed to stay in such a place? Why did they choose to? Perhaps because they had nowhere else to go. Perhaps this life, in all its simplicity, its fragility, and sickening poverty, and even its terrible stench, is all they have.

I left Buluan with anger burning in my chest. Anger at the shameless corruption of our government, which allows places like this to exist and fester. Anger at how human indignity has been normalized, buried in silence, until nobody dared to tell these people’s stories. Had we never gone there, we would never have known they existed.

But the world should know. The world should share this anger. Not the kind that divides, but the kind that unites. An anger so fierce it shames corrupt politicians into facing the evils they commit, the evils that reduce people to such a painful, sobering existence.

And yet, I carried with me a fragile kind of hope: that this unwelcome outsider, telling these stories and naming these injustices, might one day stir someone, anyone, to change what we saw. That someday, the laughter of the children of Buluan Lake, who now find joy in dirty, foul-smelling water, will no longer be drowned by the stench of poverty, but will rise from a place where they can finally live, and thrive, with the dignity they have long been denied.

The City Nearest the Sun

 I submitted this piece to the 2025 Arturo Rotor Literary Awards for Creative Non-Fiction. It didn’t make it to the final list, but I remain grateful for the push it gave me to finish something I had been carrying inside for a long time. I spent weeks writing it, after a burst of inspiration one evening when my colleagues and I found ourselves deep in conversation about the ills of our country’s healthcare system.

Today, I’m sharing it not as a contest entry, but as a small tribute to my colleagues and patients in our city’s public hospital -- whose courage, endurance, and quiet acts of grace continue to inspire me every day. Sayang if this piece simply slept in my computer, unread. Recognition may have eluded it, but leaving it buried would feel like a great injustice for the people it is intended for. 

I hope that in some small way, it finds its reader. And if it can stir even one person to take one concrete step toward making a lasting difference, then it will have done its work.

(This is a Chat-GPT-generated image, but this is not very far from actual scenarios in public hospitals, not just in my city, but in the rest of our country.)

The City Nearest the Sun

    The heat in the city’s lone public hospital doesn’t just press down, it sinks. It is invasive and relentless, seeping into every corner of the old, dilapidated structure and clinging to the skin of its tired occupants like an unwelcome second layer. By midafternoon, it gathers in the corners of the emergency room extension like a living presence, thick with humidity and the mingling scents of dried-up blood, urine, sweat, and impatience. As it clings to the skin, it rises into the air and merges with the constant hum of muted conversations, rhythmic beeping of machines, and the uneven shuffle of footsteps echoing against crackled floor tiles. I walk past the makeshift ward, a narrow stretch of hallway between the ER and the medical ward, lined on both sides with aging stretchers and sagging hospital beds. Adjacent to the hall, separated by a cracked concrete half-wall, is an open-air awning sheltered by a thin, corrugated sheet roof.

    Beneath it, patients wait, sometimes for days, for a space inside the main hospital wards, a place some will never see. I regret doing this now, at this unholy hour, when the heat unsettles bodies and spirits like a punishment. I should have made my rounds in the stillness of the night, when the air is cooler, gentler, and the exhaustion feels like a more forgiving guest.

    Today, as I have countless times before, I pass through this alley where a few patients have scavenged wheelchairs and have been sitting on them for days, their IV drips suspended from rusted metal stands or barely affixed hooks screwed haphazardly into the walls. Others lay motionless on ramshackle stretchers, propped against a pile of shabby, threadbare pillows or slumped forward, eyes raw and glazed by fever, jaundice, or a resignation so deep it’s almost otherworldly. Those who accompany the sick are scattered along the edges of this limbo, perched motionless on brittle plastic chairs, heads tilted back with mouths slack, caught somewhere between sleep and despair. Some surrender further to the heat, sprawling on flattened cardboard boxes spread across the bare concrete floor, their breathing barely audible above the murmur of moans, shuffling feet, and occasional cries for help. A fly circles nearby, its insistent buzz breaking through the humidity, before it lands on the untouched meal ration beside a child’s bed, a tray of cold rice beside a tiny piece of fried fish languishing with the same resignation as the faces clustered around it. Sweat pools under my collar, sticky and stifling. I wipe my neck, thinking, perhaps for the hundredth time, that this hospital is more than just understaffed and underfunded. It is suffocating, overcrowded, and teetering on the brink of an apocalyptic demise.

    I have been the only cardiologist in this hospital for many years, and on that day,I was called in once again to see patients referred for their heart ailments, each of them lying or sitting in stretchers and wheelchairs meant only for emergencies, in a corridor that has long served as a ward by necessity. The air, as always, was heavy, thick with heat and a faint whiff of disinfectant, unable to hold back the far more human odors that lingered. Everything here feels impermanent, as though held together by hope and surgical tape, brittle and unsteady, always threatening to come undone. For the past seven years, this has been my constant reality. I have made rounds in this hospital long enough to see its struggles become as routine as the electrocardiograms I read. Over the years, I have watched waves of city leaders rise and fall, each one heralding promises of progress and delivering speeches heavy with visions of reform. But here, nothing ever truly changes. The hospital’s walls seem to have absorbed the weight of these betrayals: the paint continues to peel, the ceilings continue to sag, and the unrelenting tide of patients continues to spill into every available corridor. Faces come and go in the hallowed halls of government offices, but here, beds and wheelchairs still crowd the decrepit passageways, their occupants waiting, sometimes for days, for a proper space inside the main wards, and for relief that always seems to be out of reach. This place endures, not because it thrives, but because it must. Because for so many in my city, there is simply nowhere else to go.

    I wiped the sweat from my brow, shifting the weight of my patients’ charts from one hand to the other, and stepped toward my first referral. There is no time to linger in frustration. Work must go on, not because the system works, but because the patients, lying here in the cracks of that system, need it. There is nowhere else for them to go, and there is no one else to do it.

    Manong Ernesto was the first. A stroke had ended his years at sea, fishing harder and farther away from our country’s waters for one of the city’s major tuna companies. During his younger years, he and countless others like him had cast their nets much closer to home. Back then, the city's proud moniker as the country’s tuna capital seemed appropriate, as its shores teemed with yellowfin and blue marlin, providing a steady livelihood for its coastal communities. But in the past decade, things began to change. Tuna in the southern Philippines’ waters grew scarce, and the once abundant catch diminished year by year. Fishermen like Manong Ernesto and his crewmates were forced to venture farther, beyond Philippine waters, into international fishing grounds like Papua New Guinea or Indonesia, chasing schools that seemed ever out of reach. Hypertensive for as long as he could remember, it was during one such journey, far from any doctor or medicine, that his body gave out. The stroke hit him onboard while he and his crewmates were fleeing from the Indonesian Coast Guard, who had caught them fishing in the wrong territory. The confrontation and the escape had pushed his aging body past its limits, and by the time they reached safety, his life had already changed forever. He returned home half-paralyzed and full of stories he could no longer afford to finish. Tales of oceans and hauls, of distant shores and hard-earned wages that had once brought his family a measure of security. Now, despite a Manila envelope full of prescriptions for his blood pressure medications and blood thinners, which he took only when he could afford to, this was his third stroke. His three children, once sent through school by the strength of his back and the callused grip of his hands, now have families of their own. The demands of survival had pulled them away, leaving little

room to help with his mounting expenses.

    At his bedside sat his wife, her thin frame bent by the years, her movements slowed by an arthritic knee that made fetching water or standing up to place a dry towel on Manong Ernesto’s damp and sweaty back an ordeal. She never complained. She only sat, watching him in silence, her hands folded in her lap as though holding together what little they had left. The heat bore down on her as relentlessly as it did on him, but she seemed to wait it out with a stubborn patience, as if her stillness would somehow cool the surrounding air and bring healing to both of them.

    Then there was Analyn, young and swollen, her feet, legs, even her belly stretched tight with fluid that her failing heart could no longer move. Rheumatic heart disease had shaped her life, her hospital admissions recurring with an unsettling regularity, like waves returning to shore, each one coming closer and faster as time went on. She had memorized the phrase “double valve replacement,” even if she barely understood it, repeating it like a refrain from a song she could never afford to finish. When I introduced myself, she smiled softly, a fleeting brightness cutting through her worn fatigue. She recognized me, she said, from her last admission. Shyly, she asked if I could help her with the referral letters and medical certificates she needed for her

surgery in a hospital far away, a journey as distant as her hope. I promised her I would, though in my mind I thought the words I could never say out loud: that this surgery might already be too late. Her illness looked too far gone. I saw how cachectic she had become, her frame reduced to angles and shadows, her abdomen severely distended, a belly filled with ascites instead of vitality. And now, she had a raging pneumonia, and her breathing was deep and heavy, like an iron hand pressing harder on her heart that was already close to surrender.

    Analyn could never afford the surgery, not just because of the daunting cost, but because their livelihood was already gone. She and her tribe had farmed a small patch of land that sustained them for generations, but in recent years their crops had been repeatedly wiped out by floods that came with the slightest rain. What was once their foundation for survival had become another casualty of a changing world. The fields that her family and their ancestors once nurtured now unraveled with every monsoon rain, the soil washed away before it could even catch its breath, as though taunting them with life’s fragility. For most of the year, the sun brought relentless heat, scorching the earth until cracks formed on the parched ground, and the crops stood sparse and feeble under its unforgiving fury. And yet, when the long-awaited rains finally arrive, they come not as a blessing but as torrents, sweeping away the soil before it could satisfy its thirst, leaving behind a haunting reminder of both nature’s power and its indifference.

    I knew she might not make it through this admission. Still, I stooped towards her and listened to her chest. The telltale murmurs of her damaged valves rumbled like distant thunder. I added another note to her chart, a thick file already heavy with deferred promises and dashed plans. Before leaving, I reached for her hand, smiling as I gently squeezed it. “Don’t forget to visit me in my clinic when you’re discharged,” I said, my voice careful, trying to lend strength to a hope I wasn’t sure I could sustain. “I’ll work on your referral for surgery.” She nodded, her smile small but grateful. As I stepped away, I left her with nothing but a silent prayer in my heart, a whisper to whatever power that can grant her just a little more time, a little more strength, and a little more hope that she might return to her home, ravaged by both sun and rain, just one more time.

    

    And finally, Christian. He is an inmate from the city jail, brought in for missed dialysis. His mother held his wrist tightly as I examined him, her grip firm, as though afraid someone might take him away again. I asked him about his cardiac symptoms, but his answers were sparse, barely audible. Instead, the real story spilled out in fragments from his mother’s cracked voice, a voice worn thin from years of carrying too much grief. 

    She told me how he was arrested two years ago. No charges filed; no hearing scheduled. How his friend had been less lucky, shot during a drug raid, just another anonymous death in the seemingly endless list of "nanlaban." Christian was the lucky one, she said, though the words felt so hollow they seemed almost cruel. She leaned in, lowering her voice, and confessed that although Christian denies it, she believes he and his friend had been using shabu. She added, almost with resignation, that his friend deserved what happened to him: “Sala nya man gali.” It wasn’t an opinion voiced to excuse Christian, but a reflection of how far punishment has become normalized, even accepted. And then, almost as if seeking comfort in the logic of consequence, Christian’s mother continued in a resignedly faithful tone that her son’s worsening kidneys, his heart failure, even his suffering were all, to her, part of his punishment. The disease was not seen as a failure of access or care, nor as a condition worsened by missed dialysis or incarceration. She saw it instead as a reckoning he had to endure. She loves him, yes, but her love struggles to separate compassion from the justice she believes the world demands.

    And that, perhaps, is the quiet tragedy. In his mother’s tired words, I heard not just her love for him, but an acceptance of a world that blames suffering on sin, that treats brokenness as deserved. It was a logic that shaped so many in my city, where punishment, both state-sanctioned and cosmic, had become a convenient answer to complex suffering. In her eyes, Christian’s disease was not simply a condition of the body but a moral affliction, a cruel but righteous universe balancing itself out. His mother’s contradictions reflected the prevailing logic of the world around us: that violence is a small price to pay for order, and sickness is the inevitable wage of sin.

    But still, her grip on his wrist lingered, holding him like a tether to the world, not an act of rebellion against this bitter system, but a quiet going along with it. She both loved him and believed he was burdened with this suffering out of some unknown divine justice, and perhaps she couldn’t choose which mattered more. “Swerte na sya subong,” she murmured again. Christian was lucky. Lucky to still draw breath, even when each one came through a failing heart and heavy lungs. Lucky to be alive, even if his existence was one defined by missed treatments and a wheelchair that almost didn’t fit his swollen body anymore. Lucky to have a disease his mother thought was deserved, and a world willing to let him carry it because it has already judged him. It didn’t feel like luck now. They stayed as long as they could in the public hospital because it was the only place where Christian could get dialysis. Outside the hospital walls, in the jail, there were no machines to filter his blood, and they did not have

enough finances to pay for the tricycle commute to the nearest dialysis unit. They knew it wasn’t fair to take up space for longer than necessary. They knew others were waiting for beds. But where else could they go? How could they leave?

    Christian lay there in faded orange detention pants, his shirt emblazoned with the name of a senator who had visited the ward months ago. It was a shirt for a campaign, bright with slogans, handed out alongside promises that rarely reached lives like theirs. On that day, he had been lying on one of the hallway beds when the senator noticed him, photographed him, and handed his mother 5,000 pesos, a single act that overshadowed speeches and promises of reform. His mother still called it a miracle. That it was taxpayers’ money, not a personal gesture, didn’t seem to matter. What mattered was that someone had stopped, smiled, and handed them something. Anything.

    They have been trying to stay in the hospital ever since, maneuvering the system of referrals, prolonging each admission as long as possible. Here, Christian could get dialysis. Here, they could get meals. Here, they could hope. Outside, in jail, his condition would deteriorate. So whenever he got better after consecutive dialysis sessions, he would start drinking more water. At first, I thought it was the intense heat that fueled his thirst. But later, I understood: he was drinking not just from thirst, but to survive. Because if he stabilized, he would be sent back to jail. And being back in jail meant another wrestling match with Death. Every day that Christian remained in the hospital was one more day he stayed alive. One more dialysis session that might keep him from drowning in congestion, one more reprieve from the slow unraveling that waited outside. But survival came at a price. Each day he occupied a bed meant another patient was waiting, another life put on hold. The unspoken weight of that truth settled heavily between us as I calculated his doses of inotropes and adjusted his medications, trying to make sense of the impossible equation.

    Why must it fall on us, his doctors, to decide who gets to live? If we send him back to jail, he dies. If we keep him in the hospital, in this endless cycle of dialysis, decongestion, drinking too much water, congestion, then back again, he lives for a few days, weeks, maybe months. Then dies anyway. We are caught in a healthcare Catch- 22 dilemma, where we are asked to choose between justice and dignity, between the greater good for society and the little act of kindness that we can do now. We are  mandated by the system not just to heal, but to decide whose suffering deserves to be seen.

    Just two weeks ago, one of my braver colleagues decided to discharge Christian from the hospital and send him back to jail. Yesterday, as predictable as birds returning home because they have nowhere else to go, Christian and his mother were back at the ER to start the cycle one more time.

    Christian is just one of the countless victims of scarcity, not due to the carelessness or indifference of people, but of a system forced to triage between those whose needs are equally critical. In this system, compassion and resources collide like mismatched gears grinding together, trying to move forward but breaking under the weight of their burden. I understood his mother’s desperation as deeply as I recognized its futility. In the arithmetic of scarcity versus care, there are no answers, only compromises, only losses.

    I began to think that what we do here isn’t healing. It is managing collapse. The collapse of bodies, yes, but also of systems stretched far beyond their limits: the collapse of resources, of compassion worn threadbare, of hope curled up like a watcher dozing off on a flattened balikbayan box covered only by a flimsy malong. Everything feels fragile, as though one stiff breeze or one more patient could bring it all crumbling down. The heat makes it worse. It isn’t just an oppressive backdrop, but a pathology. It warps ECG leads, drains nurses, and prematurely spoils transfusing blood. It accelerates the faltering rhythms of failing hearts and slows the already staggering steps of exhausted staff. The heat invades even the silence, wrapping itself around despair until it feels like another pulse beating through the ward.

    Just outside the makeshift ward stands the hospital's charity window, its airconditioning humming softly behind tinted glass, where paperwork is processed like prayers in an unyielding bureaucracy. The face of a senator beams down from the door: a smiling, oversized tarpaulin plastered across the entrance, a reminder of promises never intended to be kept. The charity window is both a monument and a mirage, a place where people, already desperate, are made to plead for help that should have been their right all along. 

    The tragedy isn’t just that patients must line up and beg for assistance inside their own public hospital. It is that they have grown to believe that they are receiving a gift. That some tiny portion of the taxes they have paid, shaved down to almost nothing and returned with a smile and a logo, is something extraordinary. They walk out clutching vouchers or guarantee letters, heads bowed in gratitude, rarely questioning why what should be basic has been reduced to charity. They are taught to call it benevolence. They are made to feel fortunate for crumbs. And when they return to the humid, overcrowded ward, where the heat presses relentlessly down, they happily and proudly carry their tiny victories like lifelines in a system that was designed not to heal, but to perpetuate the notion that politicians are gods.

    In the meantime, healthcare workers like me keep working in hallways, improvising care in spaces that were never meant for healing. We write prescriptions patients will most likely not fill, aware that the cost of a single pill can swallow an entire day’s wage. To free up precious bed space, we hurriedly discharge patients back to the very conditions that made them sick: to the heat that suffocates, to the poverty that starves, to the policies that grind them down. Nothing ever truly ends here. The system doesn’t rebuild people’s lives; it only magnifies their suffering. 

    It spins in circles, a loop of patched-up bodies, deferred treatments, and temporary fixes that only delay the inevitable. We see the same faces return, their illnesses worsened, their hopes dimmed. Their beds and wheelchairs in the hallways don’t just hold their broken bodies. They carry the weight of the collapse itself, a failure so vast it feels insurmountable. Yet we keep going, because the alternative is unthinkable. Because for these patients, there is nowhere else to go. And for those of us who promised to serve the underserved, who made it our life’s mission to uphold this promise, there is no choice but to stay, even in the depravity of a system that seems designed to pull down lives, and not to lift them.

    That afternoon, as I stepped out of the ward and into the open corridor, exhausted not by the amount of work but by the weight of my thoughts and frustrations, I noticed that the air had begun to shift. It was still warm. After all, this is the city nearest the sun, we like to joke, where summer isn’t just a season but a sentence, a reality we must endure and somehow thrive in. But this time, something was different. The suffocating grip of heat had eased, just enough to let the world breathe, and to let me breathe too.

    And then I smelled it: that first, familiar trace of rain, rising from the concrete and curling into the air like the faintest of promises. It wasn’t the kind of rain that arrives in thunderclaps and torrents. It was merely a whisper, but even that was enough to stir something forgotten. Watchers shifted in their chairs, their movements slow and groggy at first, as though they too sensed this fragile change. A nurse wheeled out a fan from her station, pointing it toward the patients, letting what little breeze she could muster ripple over them. Nearby, a patient gripped his crutches, his thin frame trembling with the effort as he stood and began to amble toward the toilet, each step deliberate, as though testing this new softness in the air.

    Somewhere down the hall, someone laughed. It was soft and unguarded, a sound so rare it caught me off guard. It was the mother of the child with the untouched rice, talking to her kumare, whom she had unexpectedly run into at the hospital. The kumare, her neighbor, had a patient of her own to care for, and yet, amidst the chaos of it all, they managed to find one another. It didn’t fix the sagging ceilings, the overcrowded wards, or the impossible triage of the hospital, but for a moment, it made the mess of it all feel survivable. That laugh was enough to remind me that hope, beaten down and exhausted as it often is, finds ways to rise like the scent of rain curling into overheated air.

    And I thought that maybe this is how change begins. Not with sweeping reforms or grand political gestures, but in the quiet, stubborn acts of care that insist on a future: a mother who won’t leave her son’s side no matter the cost, a husband who patiently lines up at Malasakit centers for his wife’s chemotherapy, a nurse who shares the breeze from her fan, or the doctors who continue to treat patients in this hospital, not out of obligation, but because they know that in the absence of others, they must. Change begins in these small, persistent acts of humanity that refuse to give up, even in the face of a system built on scarcity.

    Change also begins in the things that aren’t immediate and aren’t heroic but are so deeply necessary: more hospital beds funded for need, not politics, rural health units that are equipped with something as simple and essential as working sphygmomanometers, a public health insurance system that actually works, and that covers so much more than just the first few doses of broad-spectrum antibiotics. Students who are trained not just in diagnosis, but in dignity, so the health care profession becomes not only about proper diagnosis and treatment, but more about respect. Leaders who treat public health not as a podium, not as a campaign platform or viral social media post, but as an unwavering commitment to the lives that depend on it.

    There is, of course, no easy cure for a system so fractured. The wounds run deep, and the healing, if it comes, will be slow. But even here, in this city nearest the sun, something keeps trying to take root. It is imperfect. It is painfully gradual. But it is real. Hope, fragile but persistent, exists even in this place where summer is not just a season but a condition of survival. Rain, when it comes, doesn’t simply cool the air. It offers something more. Relief, yes, but also the quiet, almost defiant possibility of change. It doesn’t last long, because rain never does. But it lingers long enough to remind us why we keep going.

    And so tomorrow, we rise again. To toil under this relentless heat. To tend to the fractures, the bodies, and the stories that unfold in these overcrowded halls. And to find, in our tiny corner of shade here in this city nearest the sun, enough strength to wait for the coming of another rain. xxx

The 21st Century Learner

Sharing the poem I wrote for my homework on reflections on the 21st century teacher for my graduate class:

Hindi raw ako nagsusumikap,

Dahil mababa ang aking marka.

Pero ang hindi nila alam,

Ako rin ay lumalaban, tahimik, nag-iisa.

May mga modules at video lessons,

Na minsan ay hindi ko napapanood,

Dahil cellphone lang ni nanay ang gamit,

At madalas wala akong pang-load.

Madali na lang daw ang mag-aral ngayon,

Nasa tuktok ng daliri lahat ng impormasyon.

Subalit ako ay hirap na hirap,

Dahil sa aming lugar ang wifi signal ay mailap.

Lahat ng kaklase ko, may laptop o tablet,

May ChatGPT subscription at 24/7 na internet.

Samantalang ako, sa Zoom ay laging huli,

Kahit nga pagkain, minsan walang pambili.

Nag-aaral sila sa TikTok, YouTube, at Reddit

Nag-cocollaborate sa Viber, FB, o Google Meet,

Ako naman ay bihasa kung alin ang totoo at huwad,

Na hindi lahat sa internet ay dapat paniwalaan agad.

Sana ito ay nakikita ng aking mga guro,

Na kahit salat sa gamit, gustong-gusto ko ang matuto.

Kahit mahina ako sa makabagong paraan ng pag-aaral,

Namumuhay akong matapat, dalisay, at marangal.

The Cost of Integrity

 A few nights ago, I had a conversation with a very good friend I rarely see these days. He recently resigned from his corporate post after decades of working for the company. I guess those in sales, especially those who are pulled away from their families because of their jobs, suffer burnout the most. Anyway, after resigning from this huge company, he became the chief of staff of our congressman, who is also his close friend from way back their college years.   So from corporate, my good friend changed into a completely different path: that of politics. 

He just started his job in the congress last July 1. He then had firsthand experience of the systemic rot that pervades the hallowed halls of government, especially congress. He saw how contractors literally bring bags of cash into congressmen's homes and offices, how for every project, various politicians earn a percentage of the total project fee (1% of 1 billion is a huge amount, mind you), how the construction companies already know the projects that are up for bidding way before the budget gets approved. Corruption is already so ingrained and commonplace that even the staff of these congressmen get their own share as well.   For every meeting, they get an envelope with a wad of cash. And yes, the pressure from the higher-ups is high. If you oppose the current administration, your district does not get budget allocation for your projects, no matter how noble, urgent, and necessary those projects might be. And yes, they are required to list flood control as their priority projects. Tsk, tsk.

My good friend, idealistic, kind, and patriotic as I have always known him, could not stomach it all. He tendered his resignation and will step down from his post once August ends. He only managed to stay for two months. Because that’s what a rotten system does to good people: it drives them away. Because if they stay, tiny cracks form in their walls of integrity until they eventually collapse. And they, too, become part of the very system they once swore to fight.

I am very proud of my friend. In a place where power tempts and money blinds, he chose to walk away. And that, I think, is the cost of integrity: you have to know when to walk away. As for me, I am just happy that my friend is back home, where we can climb mountains and dream about change again.

Divine Justice

 Today, I want to believe in divine justice. I want to believe that the universe keeps a quiet ledger, that the good we put into the world comes back to us, and that evil eventually devours itself. I want to believe that those who toil under the sun, breaking their backs and sacrificing their dreams, will one day reap what they have sown.

But lately, that belief has been difficult to hold.

I have been watching old Kara David documentaries that leave me gutted. Children smashing glass bottles so they can sell the shards and take home fifty pesos a day. Agta kids diving into freezing waters in the middle of the night for pugita, splitting four hundred pesos among nine of them. The children of sakadas laboring under the heat of the noontime sun, earning thirty pesos to buy rice for the family. It is poverty so stark it has no poetry, no silver lining, no redemption. Just survival.

And then, in the same breath, the news parades the “success stories” of people now embroiled in billion-peso infrastructure scandals. Ghost projects. Substandard flood walls. Billions siphoned away from funds meant to protect the most vulnerable. These same people are filmed stepping out of luxury cars (which they bought because they like the umbrella or the wine glass), displaying their bags, their watches, their lives of excess. And they call it wit. Strategy. Business acumen. Media even sells it as something aspirational, an inspiring “rags to riches” tale for Filipinos who have been working honestly, grinding quietly, and still barely making it to the next day.

It is devastating, this betrayal.

I want to believe that there is a cosmic reckoning. That the ones who steal from the poorest among us will suffer, that they will taste despair so sharp they will wish for death. I want hell to exist, and for it to start early for those who profit from the hunger and broken dreams of others.

I want divine justice to be real. I want the universe to intervene, to hurl its thunderbolts and demand penance from those who rob us blind. And yet, I also know that divine justice, if it exists, is slow. Sometimes it never comes.

Which means the weight falls on us. If heaven does not intervene, then perhaps it is our responsibility here on earth to choose better, demand better, be better. 

Because corruption does not begin with billion-peso scandals. It starts small, quiet, almost invisible. It is the little unethical acts we normalize until they snowball into systemic decay. A pharmaceutical grant in exchange for prescriptions. A shortcut offered for a favor. A “gift” accepted because “wala namang mawawala.” These things seem harmless, but each one chips away at our collective integrity until we wake up in a country where stolen billions barely shock us anymore. Corruption does not exist only in government. It exists in our own lives, and thrives wherever we allow convenience to trump conscience. 

Corruption pervades every layer of society because we allow it to. And if we keep excusing it saying “wala namang masama,” “normal na ’yan,” “lahat naman gumagawa niyan”, then we are part of the same machinery that breaks this country apart.

Divine justice will come someday, I am sure of this. But we don't have the luxury of time to wait. The reckoning must begin with us. We need to examine our own lives.  We must examine our own ranks, whatever profession we belong to, whatever job we hold. We need to stop normalizing small acts of dishonesty, to stop glorifying ill-gotten wealth, and to teach our children that success without integrity is hollow. Because if we don’t, the cycle continues. Our people continue to suffer, while the corrupt build their kingdoms above our silence.

And finally, we need to demand accountability. We need to seek transparency. We need to remind our government officials who they are supposed to serve. We need to show them that those who are corrupt suffer the consequences. It doesn’t take divine justice. It only takes a people who refuse to stop watching, who refuse to forget, and who refuse to forgive.

The Case For Asking

 

If we are shopping for a new phone, we ask first, "Magkano po ito?" If we are hiring someone to build our dream house, we ask, "Magkano kaya ang aabutin nito?" If we ask a lawyer to represent us in court, we ask, "Magkano ang PF mo, Attorney?" Even when we buy mangoes at the palengke, we ask the price before we negotiate.

So why is it so uncommon, almost taboo for patients to ask doctors, “Doc, how much do you usually charge for your services?”

Doctors don’t have standard rates across the board. Our fees are shaped by a mix of factors: complexity of the case, urgency and risks, type of institution, location of practice, years of expertise, scope of services, and even personal values and principles. And ahh yes, included in that list is the difficulty and attitude of the patient and the family members (I'm smiling, but not joking).

Some of us deliberately charge below the norm because we believe that healthcare should be accessible. Others match industry standards to ensure long-term sustainability: for themselves, their staff, and their families. And yes, some charge higher, and may have very good reasons for doing so. These could include the rarity of their specialization, the intensity of their training, or simply the number of hours they spend at work and in continued learning.

Over the years, various medical societies have attempted to standardize professional fees, releasing guidelines and tariff schedules to help physicians navigate the complex landscape of pricing. But our profession is unlike others, it is both a science and an art, a business and a calling. The truth is, in these offical society statements, the disclaimers are often longer than the prescribed rates. “Depends on the case,” “Depends on the hospital,” “Depends on the procedure”, "Case-to-case basic", "Upon the discretion of the physician". We’ve all said those lines before. Because pricing in medicine is never one-size-fits-all.

Every doctor is different, and so is every patient. Which is why transparency is key. And the best way to begin is to simply ask.

So my proposal to this perennial professional fee issue is simple: wouldn’t it be better if we normalized the question, “Doc, may I ask how much your PF is for this kind of case?”

It is not offensive; it is practical. It empowers the patient. It opens the door to a respectful conversation where the doctor can explain the range, the rationale, and any possible caveats, such as added procedures, complications, or extended care. It also avoids later awkwardness, or worse, assumptions of greed.

Surgeons and anesthesiologists can do this. Why can't internists?

Patients deserve transparency. But transparency is a two-way street. If a patient is expected to trust a doctor with their body, health, and sometimes even their life, then trust must also extend to finances. And when that happens, when patients ask before doctors render their services, and when doctors answer with honesty and fairness, we meet each other with dignity. There’s no guilt. No awkwardness. No insult. Just mutual respect.

It is true that the physician-patient relationship is a fiduciary one. It is built on trust, shaped by the ethical imperative that doctors always act in the best interest of the patient. And whether we like it or not, this relationship is inherently unequal. The physician holds the medical knowledge, the tools for diagnosis and healing, and often, the authority within the room. The patient, by contrast, is vulnerable: physically, emotionally, and sometimes financially.

This is precisely why transparency matters.

Even with this asymmetry, or in my opinion, perhaps because of it, we must strive to bridge the gap in all the ways we can. And one of the most accessible and respectful ways to do that is to talk about money: clearly, kindly, and early.

To empower patients is not to deny that the relationship is unequal; it is to acknowledge it, and then to offer clarity as a form of care. When patients feel informed about their treatment and about the costs involved, they feel safer, respected, and more in control. And when physicians are asked respectfully, not second-guessed or assumed to be greedy, we are reminded that trust can be mutual.

And once the patient and the family are informed, they can now be empowered to negotiate. To me, and I am not speaking for the entire profession, it is never wrong to ask if something can be made more affordable. But context matters. Timing matters. Tone matters. And assumptions, especially the ones made without knowledge, can bruise even the most compassionate hearts.

So if you’re a patient, ask first. I hope that while you trust us with your health and with your lives, you also trust that we are not doing what we do to enrich ourselves. 

As for me, I can promise that when you ask, I will answer clearly and with care. And I will listen to your negotiation with compassion and justice. 

A Healer, Not a Haggler

The truth is, I charge way below standard professional fees. Many times, I don’t even collect, and often, my patients happily carry a stash of medicine samples from my clinic, which cost more than my professional fee. I’ve had patients walk out of the clinic saying, “Hala, tun lang PF ni Doc?” Relieved, surprised, and maybe a little guilty. Some of the colleagues I have worked with have even asked the nurses, "Mabubuhay kaya si Jean jan sa PF nya?"  I take that as a compliment.

I chose this profession because I wanted to help people. And yes, because UP has "brainwashed" me into making serving the underserved my ultimate goal, I take that goal seriously.

So when someone assumes, let me emphasize the word "assumes",  that I must be charging too much, it stings. Not because of the money, but because of what it implies: that I need to be bargained with. That this profession I have loved deeply, trained for with both discipline and delight, can be haggled down like produce in a palengke. That something rooted in compassion and science, something I’ve poured decades of curiosity and care into, needs to justify itself before it is paid for.

Let me be clear: I understand that times are hard. I understand what it’s like to count coins for a consultation. I have waived my PFs many times, without being asked. In fact, I price my fees in such a way that patients can retain their dignity without needing to beg. Because if people are sick, and made poor because they are sick, then the least they deserve is to keep their pride. I feel sad when they have to set their pride aside to ask for discounts. So I have always made sure that my PFs are fair and lower than standard rates, rooted in the principles of justice, compassion, and kindness.

But what I struggle with is the assumption that I must be overpriced. That I must be earning too much because I am charging too much. That I must be made to prove I’m not greedy before I even open my mouth. 

This week, the internet lit up with a commentary from Ramon Tulfo, who called out a doctor at the Philippine Heart Center for allegedly “overcharging.” Many were quick to judge. Few paused to ask what the full story was. Medical groups stood by the physician, stating that the professional fee was fair, compassionate, and reasonable. That the doctor had, in fact, already lowered it.

We do this all the time. Quietly. Out of compassion. But that compassion is neither limitless nor owed.

Doctors are people, too. We have bills to pay, families to raise, and dreams to chase. What we do is a vocation, but that doesn’t mean we should be asked to live off vocation alone. We cannot keep patching a broken healthcare system with our own self-sacrifice. Compassion should not require self-erasure.

And when the system fails, as it often does, it is not just the patients who suffer. As my UP-NTTCHP professor, Dr. Nemuel Fajutagana, so powerfully put it: "If we truly value life, we cannot keep patching a broken system with the sacrifices of those who hold it together. The dignity of patients matters, and so does the dignity of those who care for them. If we want a healthier Philippines, we must fix the system, , not break the people who sustain it."

If someone took the time to ask, “Doc, how much is your PF usually?” And then, after hearing the fee, said, “Would it be possible to lower it a bit?” Now, that’s a negotiation. That is honest communication. And I appreciate patients and their families when they do that.

But asking for a discount without even knowing the price? That is so disheartening. And when it happens after the first or second visit, after trust has supposedly been built, it is even more infuriating. Because that’s like handing me a message that says, “I trust you enough to save my life, but not enough to pay you fairly.”

Worse, it feeds into a painful, misguided narrative that medicine is now just business, that those who took an oath to heal have turned it into a profit-making, self-serving machinery. That the profession I love, the one many of us have dedicated our lives to with sincerity and sacrifice, has somehow gone to the dogs and that we physicians have turned into the devil himself. It is unfair. It is untrue. And it breaks my heart.

So please. Ask first before assuming I’m too expensive. Don’t haggle before hearing me out. Respect my work the way I respect your pain. Stop assuming the worst of the people who are trying their best.

I am a healer, not a haggler. And I believe we can meet each other where kindness and respect live.