Noel, Philippines
Driving Home on a Moonlit Night
By Noel P. Pingoy, MD
I am amazed at how the once quiet community where you knew almost everyone was replaced by a bustling city with busy traffic, constricting public spaces and peripatetic strangers. The old-timers must be baffled at the steady growth of the old hometown and maybe even more bewildered why the next generation is exultant to embrace the new way of life.
But things get even more surreal every time I drive home from General Santos City to Koronadal during late evenings when only the moon glow illumines most of the 60-kilometer stretch alongside undulating cornfields and pineapple plantations, tranquil towns and sitios in deep slumber. I usually end clinic late, and driving home becomes my day ender. There in the car at a cruising speed of 80 kph, I often ruminate on the day’s events and their meaning, to be interrupted sporadically by a rootless mutt or an incoming truck with blinding headlights on high beam.
Leaving the hospital fifteen minutes past midnight, I realized that this day was particularly difficult with the usual line of patients struggling with the inadequacies and iniquities of the current health care system. A twenty-seven-year-old mother with breast cancer that has spread to the lungs is afraid that she might be leaving her three-year old daughter to a husband who does not seem to care. Due to financial constraints, an elderly farmer with nasopharyngeal cancer has opted for supportive care instead of the expensive radiotherapy because he could not bear to pull his son out of his last year in college and thwart the young man’s dream of becoming an engineer. After the rounds, I reviewed some slides and was heartbroken to come across a young friend’s blood smear that displayed blasts, abnormal cells that are indicative of an acute leukemia. It is like a death sentence in the face of his family’s material scarcity.
Entering the poblacion, I surveyed the landscape and imagined for one fleeting inadvertent moment how this busy commercial district once resembled the vast verdant paddock that my siblings and I used to consider our playground. Where my siblings and I used to run around, catching grasshoppers and dragonflies or hunting spiders, or playing hide and seek with Rex and Dennis, our beloved mongrels, on warm summer days and with neighbor-friends on moonlit weekend evenings.
Summers then were quite punishing. I remember the times when brownouts were frequent; we had to stay outdoors often, under the trees, beside a brook, or at my uncle’s farm. And the start of the rainy season was a welcome relief; the heat was more bearable, and the constant pouring in the afternoon was an invitation to run around in complete abandon. Since most roads then were unpaved, we had individual puddles in the middle of the street that became exclusive wading pools.
But sometimes I had issues with the beginning of the rainy season. The grasshoppers and dragonflies became rare. Sightings of spiders were sporadic. Times spent with friends became scarcer with the onset of the rain. I often wished for bright mornings when I could see my friends again.
Changes notwithstanding, my hometown remains the same place in many ways that mattered to me for ages. The landscape of my beloved Koronadal might have altered over a short span of time, but I am comforted by the thought that people take some time to change.
I often discover this when I go home on weekends to be with family. Despite the six-lane highway, new business establishments and burgeoning midlife concerns, friends often stop, wave and smile when they recognize you. You lower the windows, slow down a bit, and gesture back. They ask you how the parents are. They tell you how this friend has gout and yet won’t stop his daily dose of beer, or this former classmate whose blood pressure is way up the stratosphere but won’t quit smoking. They tell you how they met old teachers who haven't aged a bit. They offer you turon (a Philippine snack made of thinly sliced bananas rolled in a spring roll wrapper and fried till the wrapper is crisp) and bandi (a local peanut brittle). They welcome you to their homes like a long-lost brother. They share triumphs and heartbreaks, secrets and anecdotes.
This is the sort of kasimanwa (co-residents) I grew up with and got to stay connected after many years.
In my adult life, especially in a profession that exposes me constantly to death and dying, I have learned that the changing of the season is a necessary part of life. That’s how old things make way for the new. That’s how the world remains fresh and bright. People dear to me have died. Inday, my younger sister who chased butterflies and grasshoppers and dreams with me in our field of joy, perished in a plane crash twenty years ago while on her way to a medical mission in Cagayan de Oro City. An anesthesiologist, she was with a surgical team composed mostly of friends from medical school in Iligan City. Some things happen beyond the realm of human understanding.
A colleague had just died from pancreatic cancer that has resisted even the most advanced targeted therapy. I had a chance to take care of him for a few weeks and wondered how things as dreadful as cancer can happen even to the best and brightest among us.
He must have realized the arduous struggle he was facing because despite advances in diagnosis and treatment, disease-specific survival with pancreatic cancer has not significantly changed in the past four decades, regardless of disease stage. In the Philippines, one of two patients dies within 6 months from diagnosis while the other does not live beyond a year. It is curable in only a minority of patients with localized and resectable disease. Pancreatic cancer, according to American Cancer Society Facts and Figures 2018, has the highest mortality rate of all major cancers as 74% of all patients die within the first year of diagnosis. Patients with metastatic disease have a five-year survival of 2% or less. In comparison, the 5-year survival rates of the more common stage four malignancies fare better: lung cancer has 10%, large intestinal tumors have 11%, and breast cancer, 22%.
Among the famous people who have succumbed to this dreaded disease are Aretha Franklin, Steve Jobs, Patrick Swayze, Luciano Pavarotti, Joan Crawford, Marcello Mastroianni, Michael Landon, Rex Harrison, and Henry Mancini.
The pancreas, derived from the Greek pankreas (all flesh), is an organ that is about six inches long and located deep in the belly between the stomach and the backbone in the upper part of the abdomen. It secretes hormones and enzymes to digest fats in the diet. One of these hormones is insulin which prompts the body to use sugar in the blood rather than fat as energy. Diabetic patients have low insulin levels and consequently suffer from abnormally high blood sugar.
Few risk factors for developing pancreatic cancer are defined. The risk for cigarette smokers is nearly twice that for those who have never smoked. Family history of pancreatic cancer, chronic pancreatitis, alcohol use, obesity and diabetes are risk factors. Sadly, none of these so-called risk factors was present with my friend.
There he was, barely able to speak, completely under the loving care of his family, slowly wasting as cancer ravages his mind and body. He would struggle forming words to communicate what he felt or wished. But there was no mistaking the sincere smile of recognition, even of gratitude or of goodwill, each time I made rounds.
On that fateful day, I struggled with what is probably the hardest birthday wish I will ever get to write because the poignancy is not lost in the pain and absurdity of the turn of events. But one that needs to be spoken of nonetheless. B passed away on his wife A's birthday. And the latter is someone I knew all my life, having seen sunsets fall quietly through the acacia trees at the old Notre Dame campus from elementary through high school or quietly enjoyed late evening conversation as we were seated at nearby tables while our respective kids were enjoying burger and soda at McDo.
That they are both physicians (he was an ENT specialist; she, a dermatologist) was not lost in the irony of things. Some things happen beyond the realm of human understanding. They are private, soft-spoken, kind individuals. They are a couple who were never known to raise their voices, the proverbial people who could never hurt a fly. And when I think about someone losing her reason for being brave and strong on her birthday, I can only pray that the quiet, tenacious and boundless love that they shared will be the family's refuge in the uncertain days ahead.
Og Mandino once wrote, “I will love the light for it shows me the way, yet I will endure the darkness for it shows me the stars.” I cannot speak of any greater sibling devotion than what Inday and I shared. Or the unyielding tenderness A had for B. The seasons have destinies of their own, much like my beloved hometown or my sister’s untimely demise or Ben’s long-drawn-out struggle. Or the chorus of crickets after the rain and the abundance of grasshoppers and dragonflies in summer. I can no more prevent them from transgressing what small of piece of comfort remains in the darkest hours than I can nurture them to the fullest in the greatest of days.
Stepping out of the hospital that evening, I had the opportunity to appreciate the moon's fullness in a bleak Marbel sky. It quietly taught me that as the moon reflects the sun in the utter darkness of night, an unlocked heart brings hope, love and joy to those struggling in the shadows. Science textbooks used to tell me that the moon is barren, dim and cold, and its glow is only a reflection of the sun's vast powers.
The earth’s only satellite hovers 384,400 km above most of our lives except for the times when it disappears in the dark of night. The rhythm of the moon's phases has guided humanity for millennia, at times for mystical reasons. Its gravity pulls at the earth, causing predictable rises and falls in sea levels known as tides, much like the ebbs and flows of daily lives, and particularly reflective of the quotidian struggles of patients with cancer.
Due to gravity, water on the side of the earth nearest the moon, bulges upward. This phenomenon, commonly known as high tide, is also seen on the side farthest from the moon due to inertia. Low tides, when water drops down, occur between these humps. The moon's gravitational pull may have been a key to making earth a liveable planet by moderating the degree of wobble in axial tilt, which led to a relatively stable climate over billions of years where life could flourish.
Even today many people think the transcendent powers of the full moon induce erratic behaviors, psychiatric hospital admissions, suicides, homicides, emergency room calls, traffic accidents, fights at professional hockey games, dog bites and all manner of strange events.
There is a more serious problem for fervent believers in the lunar lunacy effect as there is no evidence that it actually exists. Florida International University psychologist James Rotton, Colorado State University astronomer Roger Culver and University of Saskatchewan psychologist Ivan W. Kelly have searched far and wide for consistent behavioral effects of the full moon. In all cases, they have come up empty-handed. By combining the results of multiple studies and treating them as though they were one huge study—a statistical procedure called meta-analysis—they have found that full moons are entirely unrelated to a host of events, including crimes, suicides, psychiatric problems and crisis center calls.
Similarly, as complex and multichambered the human heart is, no one could squeeze an ounce of love from the auricles, valves and ventricles. Instead it pumps blood that nourishes the many tissues and organs in the body, and when an individual is confronted with fear, danger, excitement or unspeakable joy, the heart accelerates to levels that reflect the complexity of an individual's struggles.
I had come to realize that in the face of my vulnerabilities and heartbreaks, my patients and their families appeared like moon in my night, bequeathing a glow that made my struggles easier to move through, my burdens lighter.
So, I just have to rely on memories—my hometown when the creek was teeming with fish, the fields were a playground for grasshopper hunting, my sister Inday waving an excited goodbye before boarding the plane that fateful February morning and muttering a poignant and bittersweet see-you-soon — to help me see through the cold grasp of pelting rain. And in most cases, even when I know that it is never enough to assuage the burning pain in my chest, I pray.
I also constantly pray for my patients. But I have grown to endure the cruel reality that most of them might not even get well despite my best intentions and most arduous ministrations. There was a time when I felt like quitting when within a span of 24 hours, I had ten mortalities. Ten deaths in a day were horrifying, I began questioning my competence. I did nothing that day except lead the CPR team, pronounce patients dead, comfort the next of kin, address their emotional needs and sign death certificates. It did not help that the tenth was a good friend, a promising young doctor with malignant astrocytoma, a brain cancer from arises from the most abundant cells in the organ called astrocytes.
Over the years I have learned to accept the inevitability of death and dying as a facet of life. And this is an area that I feel I could be of help to my patients and their families. To prepare them for the inevitable. To make the journey as safe and as pleasant as possible.
In her book Illness as Metaphor, Susan Sontag wrote: “Illness is the night side of life, a more onerous citizenship. Everyone who is born holds dual citizenship, in the kingdom of the well and the kingdom of the sick. Although we prefer to use the good passport, sooner or later each of us is obliged, at least for a spell to identify ourselves as citizens of that other place.” I would want to be beside my patients when the bad passport is called up.
My patients and their families, my fellow doctors and health care providers including the nurses, medical technologists, pharmacists, utility workers, even the security guards, have constantly taught me that to be truly a caring person, one can rise above all the shadows, constrictions and judgments of others without denying our person. When we honor friendships - or simply, relationships - we consciously rage against the assumption that this life is merely a cold, dark and barren satellite high above the orbit. Instead much like the moon that illuminated my sky for many nights, I say thank you to those who reflected what I always knew about the fullness of life and the goodness of God, love and joy have always been there all along, becoming truly incandescent in the darkness of my nights, in the gravest of my days.