Jrournal ofmedical ethics, 1991, 17, Supplement 42-50

Medical professionals and human rights inThe PhilippinesJune Pagaduan-Lopez University of The Philippines, Manila, The Philippines

Health and human rightsFor most Filipinos access to primary health care is a

luxury. Often those in greatest need subsist indesperate poverty where living conditions foster illnessand disease. Well over half the population live in ruralareas without safe drinking water wherecommunicable diseases, which are preventable andcurable, account for 43 per cent of total deaths. ThePhilippines has the highest incidence of tuberculosisschistosomiasis, and polio in the Western Pacific.

Sadly enough, Filipino children suffer and die frompneumonia, nutritional deficiencies, gastroenteritisand colitis at such a rate that they make up nearly 25per cent of total deaths in the country. Beneath thesurface of these statistics lies the insidious role ofpoverty: malnutrition, for example, often aggravatesmeasles, leaving affected infants susceptible to suchcomplications as pneumonia and various forms ofdiarrhoea.

Health care deliveryChronic underdevelopment in The Philippinesexplains much of this country's poor health record.Almost 75 per cent of Filipinos live below the povertythreshold, defined by Manila's Centre for Researchand Communication as the equivalent of US $1,000 a

year for a family of six. In 1985 alone, over threemillion people, or 15 per cent of the total labour forceof 20.6 million, were out ofwork. Six years later, underthe Aquino government, the figure has increased to20.2 per cent according to the July 2 1991 issue ofAngMalaya, a Manila daily. That same year, the averageemployed labourer earned no more than US $60 permonth.

This grim picture is compounded by inadequatetransportation and communications systems whichhamper the ability of rural residents to reach healthfacilities in central towns and cities. Even in urbancentres the high cost ofprolonged institutional medicalcare is far beyond the means of the average wage-earner. Hospitals often have to get by with inadequatesupplies of x-ray film, bed linens and antibiotics. In1983, for instance, doctors at the Philippine GeneralHospital, the country's biggest tertiary state hospital,reported that a shortage of x-ray film had forced them

to forego taking essential radiographs of manypatients. Over 50 per cent of the country's doctors andmore than 60 per cent of its nurses work outside of thecountry. Of those doctors who remain in the country,most have private practices in urban areas. Manila, thecountry's capital, has 15 times as many doctors asoutlying rural areas.

These conditions, however, tell only part of thestory. During the Marcos years, the health situation inThe Philippines failed to improve because ofgovenmental neglect, widespread corruption andgraft, plus intimidation of rural health care providers.Even though the Marcos government maintained ablueprint for primary health care facilities, its healthcare delivery programme was severely underfunded.In 1983, Dr Mita Pardo de Tavera, now Minister ofSocial Services and Development, estimated that, 'interms of US dollar value, for every nine dollars spentper capita on military expenditures, only one dollar wasspent on health care'. As a result, the number ofhospital beds per 10,000 population dropped from 18to 13 between 1977 and 1983. In 1985, the last year ofthe Marcos regime, the government's medicareprogramme was only able to cover 20 per cent ofhospitalisation costs, compared to 70 per cent when theprogramme was first initiated in 1969.

Equally disturbing was the fact that governmentmedicines and supplies often failed to reach hospitalsand clinics because of graft and corruption. Forinstance, the Philippine Commission on Audit, agovernment agency, reported in 1984 that the formerfirst lady's heart center had 'various anomalies'including 'the failure of management to reconcile thephysical inventory of supplies, material, property andequipment with accounting records; property andequipment amounting to 300.7 million pesos remainedunrecorded in the center's records'.But such fiscal anomalies were not limited to

hospitals in the metropolitan Manila area. In 1986,President Aquino's newly appointed Minister ofHealth, Dr Alfredo Bengzon, found that in the twoyears before the fall of the Marcos regime between 30and 40 per cent of the national health budget forsupplies and materials had been diverted into'kickbacks, corruption, and graft'. As a result,Minister Bengzon dismissed eight of the twelve district

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health officers originally appointed by Marcos's healthminister.

Today, in its fifth year, the Aquino governmentseems nowhere close to solving the myriad problems itinherited from the Marcos regime. Saddled with adeteriorating economy, destabilisation efforts fromboth right and left wing factions, graft and corruptionand poor central planning, it has often been accused ofresorting to increased militarisation to contain politicalviolence against its continued existence.At the time of writing, in spite of a state of

emergency declaration that has been in effect for morethan six months, the economy continues to deteriorateand human rights abuses to rise. The PresidentialCommission on Human Rights (PCHR) reported thatit received a total of 1,653 complaints in 1988, 1,570 in1989 and 1,880 in 1990. The Catholic-Church-basedTask Force Detainees ofThe Philippines (TFDP), hasnoted a higher occurrence of political arrest in the pastfive months - involving 305 persons, of which 70remain in detention - than at any time since the Aquinogovernment came into office. At the height of thePhilippine-US exploratory talks in Manila in May1990, 155 anti-US bases activists were arrested.

The medical community respondsFilipino doctors and health workers active in thehuman rights movement have mixed views of the roleplayed by the Philippine medical and healthassociations in defending threatened colleagues duringthe years of martial law. The national nurses'association, they say, spoke out in defence ofcolleagues who were harassed or jailed for their humanrights activities or non-violent opposition to theMarcos government. Similarly, some provincialmedical associations, such as the Quezon MedicalSociety, responded with appeals and petitions whentheir members were detained. But, for the most part,the Philippine Medical Association (PMA) remainedsilent.The PMA did, however, issue a statement in 1985

urging President Marcos to release detained doctorsinto the custody of the association so they could servetheir patients. To protect doctors, the PMA submittedto the National Assembly a proposal providing stifferpenalties for various crimes committed by doctorsagainst their patients. But such well-intentionedinitiatives were undertaken only in the last three yearsof the Marcos regime. Clearly, fear of governmentreprisals may partly explain this lack of action. Equallyapparent was the international medical community'sfailure to support and encourage the PMA to speak outin defence of Filipino health professionals in serioustrouble. It can be argued that the often ruthlesscharacter of the Marcos government, particularlyduring the martial law period, afforded professionalassociations few possibilities for securing protection ofhealth care providers. Even so, it is significant that theCatholic Church and members of the legal professiontook public positions as early as 1975 condemning

violations of human rights committed by thegovernment.

Disheartened by the medical community's failure toformalise the creation of the Medical Action Group(MAG) and clinics for the treatment of torturesurvivors, a handful of doctors banded together a weekafter the murder of Dr Remberto 'Bobby' de la Paz, adoctor working in Catbalogan, Samar, to form MAG.Among the group's founding members were the slaindoctor's wife, Sylvia, and his sister, Dr Alicia de la Paz.They soon opened a small office in downtown Manila.Now, ten years later, MAG maintains offices in severalprovincial capitals and performs a wide range of healthcare programmes, including a prison medical project, anetwork of primary health care programmes,educational seminars on the medical consequences ofnuclear war, and clinics for the treatment of torturevictims.

Since its formation, MAG has worked closely withthe Free Legal Assistance Group and theTFDP to gainaccess to detainees in need of urgent medical care. In1983, MAG reported that the following health andliving conditions were common in several, if not most,of the 100 detention centres and military stockadesthroughout the islands: overcrowding, with commoncriminals and political detainees sharing the same cell;meagre food rations (roughly 6 pesos or 42 US cents aday); insufficient medicine for a variety of ailmentsincluding tuberculosis, anaemia, gastroenteritis, andcolitis, and irregular visits by prison health personnel.These conditions, the group said, were furtheraggravated by the fact that many detainees had beenheld for a year under such circumstances.

During the first two years of its existence, MAGencountered several barriers to their gaining access todetainees who were in poor health. In 1983, forexample, MAG doctors in Manila were only permittedto attend to prisoners on three occasions. In addition,the group lacked adequate resources to dispatchdoctors to remote areas where detainees were often inthe greatest need of medical care and basic medicines.In some areas, local military commanders wereunwilling to let civilian doctors enter detentionfacilities to examine prisoners on the basis that suchvisits could only be allowed after authorisation by theprison medical system or the International Committeeof the Red Cross.

Despite these obstacles, by 1984 MAG had reachedagreements with several regional government andmilitary officials, which allowed civilian doctors accessto prisons. This new development meant thatdetainees, particularly in areas where official prisonhealth care was non-existent, could finally receiveurgently needed medical attention. Though certainlybeneficial for detainees, the fact that civilian doctorswere examining detainees in prison also meant thathealth professionals were in a better position to exposephysical and mental abuse. Clearly, to some militaryofficials, such a situation was threatening. At the sametime, doctors who ministered to political prisoners and

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called attention to abuse often left themselves open toreprisals for doing so.

Medical participation in tortureIn natioas where state-sanctioned torture becomesroutine, it develops into a malignancy of the bodypolitic, prompted and sustained by the actions ofpeople in many sectors of society. Sadly enough, healthprofessionals may be co-opted into the practice oftorture techniques which leave few physical signs, or tomonitor a victim's heart and respiratory activity so heor she does not die unexpectedly.

Professional complicity in torture has been welldocumented in such countries as Chile and Uruguay.In the case ofThe Philippines, however, there is littledirect evidence that military and police medicalpersonnel systematically transgressed their ethicalresponsibilities by participating in torture. Even so,Philippine human rights groups now possess severaltestimonials in which former detainees allege thatprison medical personnel often treated them withindifference or outright hostility.

In one case, a psychology student in northern Luzonreported that after his arrest in 1983 a PhilippineConstabulary intelligence officer repeatedly punchedhim in the stomach and neck, and at one point bangedhis head against the wall. The beatings stopped, hesays, when his mother arrived at the detention centre.Three days later, a prison doctor examined him andsigned a medical certificate stating that he bore no signsof ill-treatment even though he had signs ofbruising onhis stomach and head and had told the doctor of histreatment at the hands of the intelligence officer. Afterhis release, the detainee filed a court complaint againstthe officer, but it was dismissed on the basis of themedical certificate.

In another case, Vicente Ladlad, who was detainedin 1983 and held in solitary confinement for two yearsand nine months, states that in his first week of solitaryconfinement guards never allowed him to sleep andthreatened him with 'salvaging' (extrajudicialexecution by military or paramilitary agents) for failingto co-operate with his interrogators. On the sixth day,he ran a fever and was examined by a doctor. After theexamination, Ladlad says, the doctor turned to hisinterrogator and said: 'Kaya pa niya' ('He can still takeit').

Another case was that of a couple personally handledby the author. Both were referred for seriousemergency psychiatric conditions only several daysafter their arrest. The wife had attempted to commitsuicide by slashing her wrist while the husband haddeveloped an acute psychotic reaction. In spite of awritten request from the relatives and legal documentsshowing that the author had military clearance toexamine the patients, she was denied access to thesetwo victims. Upon release in 1986, both reportedhaving been seen by the military camp medical officer.They were prescribed tranquillisers but were neverreferred for a psychiatric evaluation.

A well publicised case of torture under the Aquinogovernment is that of Randolf Corteza. Corteza was anurse and a part-time medical representative at thetime of his arrest. Swift legal action forced the militaryto produce Corteza and allow him to be examined bycivilian doctors. Corteza was found by a medicolegalofficer of the National Bureau of Investigation and aMAG doctor to be heavily bruised and burned over hisgenital areas, only two days after the issuing of amedical clearance by a military medical officer.Whether such incidents were isolated cases or part of

a pattern of professional misconduct remains unclearas neither the PMA nor the PCHR have formallyinvestigated the role of medical personnel in thetreatment of detainees. It would seem timely, in thepost-Marcos period, to review the status of healthpersonnel. What for example, are the lines ofresponsibility for military and prison doctors in ThePhilippines? Do they report directly to non-medicalsuperiors? And if so, are they required to share withthem a patient's medical file without his or her priorapproval? What procedures exist for prison or militarydoctors who wish to lodge complaints about torture orill-treatment of detainees?

The forensic sciences and human rightsinvestigationsForensic science is defined as the application of scienceto the judicial system. It is a field of science thatencompasses a wide range of scientific disciplinesdirected toward the resolution of legal and socialcontroversies through the application of scientificprinciples and methods of analysis. Since the turn ofthe century, the forensic sciences have grown into anamalgamation of several different scientific disciplines- anthropology, archaeology, pathology, toxicology,chemistry, radiology, and odontology - with the goal ofmedicolegal examination of evidence and thepresentation of these results and their interpretationsto courts of law.As with other scientific endeavours, forensic

scientists are expected to be technically competent intheir area of expertise; to treat all problems with equalthoroughness; to maintain complete objectivity andremain non-partisan in their examinations ofevidence;and to write reports and deliver testimony in a mannerunderstandable to non-scientists.

Clearly, forensic scientists can play an importantrole in investigations of violations of human rights.Through the scientific examination and analysis oflesions, forensic pathologists can detect physical signsof torture, their age, severity, and causal factor. Inaddition, they can perform autopsies on persons killedunder suspicious circumstances to determine the causeand, in some cases, the manner ofdeath. By combiningtheir specialised knowledge and skills, forensicanthropologists, odontologists, radiologists, andpathologists can exhume, identify, and establish thecause ofdeath of the skeletal remains ofpersons alleged

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to have been killed in official custody and later buriedin a single or mass grave.

It is not surprising, however that forensic scientistshave rarely been involved in human rightsinvestigations. Central to the practice of the forensicscientists is the concept of legitimate authority. Forwithout a legitimating authority that applies the law inaccordance with international norms, the very conceptof the forensic sciences is undermined. As a result,forensic scientists living under repressive regimes faceseveral obstacles in the application of their professionalskill and expertise to the resolution of possible humanrights violations. In countries where abuses arewidespread, forensic scientists are likely to be atserious personal and professional risk if they produceexplicit evidence at variance with official explanationsor which implicate govenment agents in the case underinvestigation. Finally, because forensic scientists workclosely with official investigative agencies, they may beeasily co-opted into covering up crimes committed bystate authorities.

Because of these limitations, few large-scalemedicolegal investigations of human rights abuseshave taken place in countries with repressive regimes.Nonetheless, in recent years the newly electedgovernments of Argentina and The Philippines havebegun to investigate the atrocities of their militarypredecessors. And in doing so, they have called on theinternational forensic science community to assistthem in the collection and analysis of medicolegalevidence. One of the most important aspects of theseinvestigations has been the training of Argentine andFilipino scientists in the specialised skills required toexamine physical evidence which, over time, may havebeen tampered with or left unrecovered.

The medicolegal system in The PhilippinesThe medicolegal system in The Philippines, as in otherunderdeveloped countries, is not as advanced assystems in countries with greater resources. In theUnited States, for instance, there has been a tripling offorensic science resources since 1967 to stem anupsurge in violent crime and drug abuse. As a result,there are now over 300 forensic science laboratoriesthroughout the country, as well as hundreds ofcoronerand medical examiner offices at the state, county, andmunicipal levels which investigate unattended,suspicious, and violent deaths.Today there are three official investigative bodies in

The Philippines - the Philippine Constabulary, theWestern Police District (formerly the Manila PoliceDepartment), and the National Bureau ofInvestigation (similar, in many respects, to the FederalBureau of Investigation) - which maintain medicolegalbranches. The first medicolegal system was establishedin The Philippines in 1937 and placed under theauthority of the Ministry of Justice. Two years later,the Philippine government abolished the Departmentof Legal Medicine at the University ofThe Philippines

College ofMedicine and transferred its functions to theMinistry of Justice. In 1942, the City of Manilaestablished its own medicolegal branch under thedirection of the Police Department. During theJapanese occupation, however, all of the lawenforcement agencies were consolidated under a singleagency called the Bureau of Investigation. In 1947, twoyears after the expulsion of the Japanese and a yearafter The Philippines gained full independence,President Manuel Roxas renamed the bureau theNational Bureau of Investigation (NBI) and placed amedicolegal division under its authority. Since then,most medicolegal investigations in The Philippineshave been carried out under the NBI's direction.

Unlike the medical examiner or coroner systemfound in the US and other countries, The Philippinesfollows the medicolegal officer system. While themedical examiner or coroner goes to the scene of thecrime, examines the body there, and later conducts anautopsy at the morgue, the medicolegal officer rarely,if ever, travels to the crime scene and only sees the bodyfor the first time on the autopsy table. Under thePhilippine system, local officials are authorised toappoint doctors from hospitals, clinics, asylums, andprisons as ex-officio medicolegal officers. As ofDecember 1986, there were medicolegal officers ineleven regional offices throughout the country.However, because of a shortage of doctors on the islandof Mindanao, most of the medicolegal cases on theisland are sent to the Cebu City office nearly 250 milesaway on the island of Cebu.The medicolegal officer system, as many Filipino

doctors and pathologists concede, often means thatautopsies in criminal cases are performed by medicalpractitioners who possess limited or no knowledge offorensic pathology. According to Dr Ricardo GIbarrola, NBI Assistant Chief Medicolegal Officer inManila, 'Some members ofthe medical profession havebeen inclined to regard medicolegal matters withabhorrence. They consider them as an addition to theirusual duties while others refuse to handle medicolegalcases because of fear or because of the waste of timeinvolved when they are summoned by the courts'.Moreover, since most of the regional medicolegaloffices have no morgues of their own, autopsies areoften conducted in funeral homes or even in the homesof victims.

Unless a complaint is filed by the relatives of thevictim or other concerned persons or groups, aninvestigation to determine the perpetrator of the crimeis usually not conducted. If it is determined that therewere no witnesses to the crime or the witnesses cannotbe persuaded to testify, which is the usual case ininstances of 'salvaging' and torture, or if it cannot bedetermined how the crime was committed, secondaryevidence, such as photos can be submitted as evidence.The collection of appropriate evidence however hasproved difficult for lawyers who have attempted toprosecute such cases. Expert witnesses, usuallydoctors, are called upon to give their opinions. But

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human rights lawyers have experienced cases wheretwo contrary expert witnesses' testimonies have beenpresented and the judge has had to decide whichtestimony is to be accepted by the court. Even with thesubmission of autopsy reports and medical findings, ifthere are no witnesses, the courts may dismiss the casebecause they believe there is no one to prosecute orestablish a case against.During the Marcos years, these conditions, as well as

the lack of independence of the judiciary, meant thatfew cases of human rights violations particularly thoseinvolving torture and 'salvagings', were everinvestigated. An unprecedented series ofinvestigations did take place, however, following the1983 assassination of Benigno Aquino Jr. Clearly, thenational and international stature of the late senator,coupled with questions of the possible high-levelgovernment involvement in the planning andexecution of the crime, made the Aquino caseexceptional. Even so, the events surrounding hismurder and the irregularities in the subsequentinvestigation illustrate how easily the forensic sciencescan be manipulated as well as the extent to which therule of law in The Philippines had been eroded underthe authoritarian government of Ferdinand Marcos.

Presidential Commission on Human RightsThe medicolegal investigation of Benigno Aquino'smurder strained the capabilities of the Philippinejudiciary and medical profession. But the slain senatorwas not alone in his fate, and Corazon Aquino is not theonly human rights widow of the 1970s and 1980s. InThe Philippines, there are thousands of namelessAquinos. All of them have become the inevitableresponsibility of the PCHR.Weeks after assuming the presidency, Corazon

Aquino established the commission and appointed thedistinguished lawyer and former senator, Jose WDiokno, as its chairman. The commission is charged toinvestigate past and present governmental humanrights abuse and report its findings to the president.For the most part, the PCHR has been concerned withassisting the government to formulate measures aimedat protecting human rights and with establishing aprocedure for receiving human rights complaints.

In its first interim report (Resolution CHR-No 1,April 14, 1986), the seven-person commissionproposed several measures to improve compliancewith, or to strengthen, existing laws related to humanrights. The measures included: disarming anddisbanding of paramilitary groups; banning secretarrest and detentions and incommunicado detention;suspending from office those charged with humanrights abuses; increasing the penalties for thoseconvicted of human rights abuses; making certainrights absolute even under martial law; allowinginspection of all detention centres, and ratifyingProtocol II of the Geneva Convention. Alas, none ofthese recommendations have been implemented by theAquino government to date.

UNRELEASED DETAINEES

One of the commission's primary functions has been toreview the cases of political prisoners who haveremained in detention despite presidential amnesty.Human rights groups claim that instead of releasingthese detainees, arresting officers have resorted tobelated charges of criminal offence such as robbery andmurder. Technically speaking, persons charged withcriminal offences fall ouside of the president's amnestyand are therefore ineligible for immediate release.By June 1986, the volume of criminal cases

'allegedly tainted with political colour' had reachedsuch a level that commission members queried theMinister of Justice on the matter. The latter replied,saying that there was little he could do in such casesbecause a release petition could only be considered'after the trial fiscal and/or the offended party shallhave been given an opportunity to be heard' by acriminal court. He did suggest however, that personscharged with criminal offences but who may, in fact,be held for political reasons, 'could be released throughthe process and application of the rules of bail'.For these detainees the prospects of release, let alone

a speedy case review, appear to remain uncertain forseveral reasons. First, the dockets of criminal courtsare overloaded, creating a backlog of cases that maytake months to resolve. Second, many detainees areimpoverished subsistence farmers who are unable topay bail costs. Finally, detainees held in the provincesoften lack assistance from legal counsel except where itis offered on a volunteer basis through such groups asthe Free Legal Assistance Group, which retainslawyers in some, but not all, areas of the country.

ARBITRARY KILLINGS

Despite the Aquino government's efforts to bring thearmed forces under full civilian control, the PCHR hascontinued to receive reports of killings of civilians bymilitary personnel and members of the New People'sArmy (NPA) and the Moro Islamic Liberation Front,in several areas of the country, particularly on theislands of Panay and Negros. The Provincial HumanRights Committee on the island of Panay reported inAugust that the increased military presence on theisland since April had resulted in 13 cases of 'salvaging'and the burning of five houses by military troops.Similarly, in September, the Moro Islamic LiberationFront, a Moslem separatist group unconnected to theNPA, claimed responsibility for an attack on a RomanCatholic wedding ceremony that left 10 people deadand 96 wounded.

FORCED RELOCATIONS OR 'HAMLETTING'

Since 1983, military operations in the eastern Misamisregion of Mindanao island has resulted in the forcedrelocation of thousands of subsistence farmers andtheir families. In June 1986, several human rightsgroups, with the endorsement of PCHR memberHaydee Yorac, sent a fact-finding and medical mission

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of inquiry to the region to investigate conditions atevacuation centres and to provide medical care todisplaced persons. The mission found that of the 4000displaced families in the area the majority had beenforced to evacuate their homes since January 1986.Evacuation centres, the medical team reported, were'totally inadequate' to meet the health needs ofevacuees. Most centres, they said, 'do not have apotable water supply. Houses are congested and veryfew have toilets. The surroundings are dirty, unfit forhealthy living. Domestic animals roam around freely'.Most alarming, according to the medical team, was

the effect that health conditions have had on childenliving at evacuation centres. In the 1970s, 'very few [ofthese] children who had succumbed to pneumonia hadmeasles', the team noted. But in the 1980s 'many of thechildren who died of pneumonia had measles too'. Theteam also found that both the number of diagnosedcases of malnutrition and deaths as a result ofmalnutrition in children had increased significantlysince the evacuations in the eastern Misamis regionbegan more than three years ago.

THE 'DISAPPEARED'

So far, the only concerted effort to apply forensicscience in investigations of human rights abuses hasbeen made by the PCHR in their attempts to identifyand determine the cause of death of the 'disappeared'.Most of the missing are assumed to have been killed bymilitary or paramilitary and later buried in unmarkedgraves.

'Disappearances' in The Philippines took a sharprise shortly after President Marcos suspended the writof habeas corpus in 1972. Some prisoners became'salvaging' victims, their mutilated bodies found by theroadside or in shallow graves, while other prisonersreappeared in military detention camps after severalweeks or months of interrogation and torture insafehouses. A third category of prisoners, however,'disappeared' after detention and were never seen againby their families, despite countless appeals to Marcosofficials.

Philippine human rights groups estimate there are666 political detainees whose whereabouts and legalstatus were never publicly acknowledged by theMarcos government. The number of 'disappearances'rose to 131 in 1984 and peaked the following year at174. And despite the Aquino government's efforts tostop the practice, 'disappearances' continue to bereported up to tiie present time. Cecilia Lagman,president of the Families of Victims of InvoluntaryDisappearances (FIND), says that many relatives ofthese 'disappeared' prisoners have accepted thepossibility that their loved ones are dead. Lagman andthe other 33 FIND members believe that most, if notall, of those still missing were killed after arrest andlater buried in remote areas.

In an attempt to aid the families ofthe 'disappeared',the PCHR asked the Minister of Health in June 1986 toinstruct all provincial health officers 'to inform the

commission of any unidentified bodies they haveexamined ... and to provide (the commission) withpertinent medical certificates'. In December 1986, thePCHR and several human rights groups sponsored atwo-week training course in the identification ofskeletal remains. An international team led by DrClyde C Snow, an American forensic anthropologist,directed the course at the University of ThePhilippines College of Medicine and carried out severalexhumations at a mass-grave site in Cavite.

Since 1984, Snow and a team of Argentine graduatestudents have been assisting the Argentine governmentin its efforts to locate and identify the remains ofnearly10,000 persons who were abducted and killed duringmilitary rule in the 1970s. Using archaeologicaltechniques, Snow and his Argentine colleagues haveexhumed and identified several of the missing andpresented their findings to civilian judges. Snow,whose participation in the Argentine forensicinvestigations was sponsored by the AmericanAssociation for the Advancement of Science (AAAS),testified in the 1985 trial of the military juntas whoruled the country between 1976 and 1983.

Thirty-four Filipino health professionals andscientists attended the forensic training course held inManila in late 1986. Among them were representativesfrom the Philippine Ministry of Health, the NationalBureau of Investigation, private health groups anduniversity medical schools. During the trainingcourse, Snow and his fellow instructors led theparticipants in the exhumation of two unidentifiedbodies, one which had been buried along the side of aremote road in the area of Cavite and the second whichhad been brought to a local cemetry and interred there.Five other unidentified bodies which had beenexhumed in the same area in Cavite and reburied inJanuary 1986 were re-exhumed. All of the remainswere taken to the medical school laboratory where theywere studied for clues as to their identity and cause ofdeath.

In addition to the Presidential Commission onHuman Rights (PCHR), the other sponsors of thetraining course were the Medical Action Group(MAG), the Families of Victims of InvoluntaryDisappearances (FIND), the Department ofPathology of the University of The Philippines Collegeof Medicine, the Argentine Institute for HumanRights, the American Association for theAdvancement of Science (AAAS), and the Committeeof Concerned Forensic Scientists (CCFS).

At the close of the training course, the participantsadopted a resolution calling on the PCHR to: create asubcommittee on 'disappeared' persons; authoriseexhumations of graves ofunidentified persons with theintention of creating a repository for the remains and adatabank of all relevant information includingantemortem medical records and x-rays; provide officialsupport for the dissemination of the knowledge andskills acquired at the workshop, and to facilitate legalproceedings against those implicated in cases of

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'disappearances' once scientific evidence had beencollected.

Medical education and the new constitutionThe most fundamental challenge that healthprofessionals face in their efforts to protect humanrights is to make governments recognise thatprofessional complicity in abuse, while not onlymorally wrong, is also a serious breach of medicalethics. Sadly, health professionals in The Philippinesand the world over receive little, if any, educationalinstruction about their ethical and legal obligations, sofar as international human rights standards areconcerned. Even so, the Aquino government'scommitment to human rights suggests that medicalschools in The Philippines should soon adopt aprogramme on medical ethics and human rights. But toensure that this takes place, medical groupsexperienced in human rights matters, such as theMAG, will have to take the lead in aiding medicaleducators in the development of course workmaterials.Much work remains to be done to develop

educational materials that address specific ethicaldilemmas in the area of medicine and health caredelivery. President Aquino's Minister of Health, DrAlfredo Bengzon, concedes, for example, thatprofessional ethics courses taught in medical andnursing schools in The Philippines are poor insubstance and have concentrated almost exclusively onissues of medical jurisprudence. He attributes thissituation to the high migration of young doctors andnurses to developed countries where they are morelikely to encounter legal liability issues in their workthan in The Philippines. As a result, he says, medicaleducators tend to neglect the more fundamentalprecepts that should guide the quality and kind caredoctors and health workers render to their patientsdaily.The Hippocratic Oath and modern codes of ethics

are testaments to the long-standing concern forstandards of conduct within the medical profession. Inmodern times health professionals and the public alikehave advocated various standards for the care of thedying and the handicapped, medical participation inthe prison health care system, euthanasia, eugenics,triage, and the cost-effectiveness of medicalprocedures. All of these issues, in addition to therelevant human rights standards pertaining to medicalethics, could be easily integrated into a medical ethicscourse.Among the international codes of ethics that could

be included in such a course are: Principles of MedicalEthics Relevant to the Role of Health Personnel,Particularly Physicians, in the Protection of Prisonersand Detainees against Torture, and Other Cruel,Inhuman or Degrading Treatment or Punishment(adopted by the UN General Assembly, 1982); theDeclaration of Tokyo (adopted by the World MedicalAssociation, 1975); Regulations in Time of Armed

Conflict (adopted by the World Medical Association,1956, 1957, 1983); the Resolution of Singapore: Roleof the Nurse in Care of Detainees and Prisoners(adopted by the International Council of Nurses,1975), and the Statement on the Nurses' Role inSafeguarding Human Rights (adopted by theInternational Council of Nurses, 1983).

Furthermore, medical and nursing colleges shouldconsider adopting the 1978 UNESCO guidelines forthe teaching of human rights. The guidelinesrecommend, for example, that professional schooltraining emphasise the lessons implicit in case studiesdrawn from indigenous human rights issues and cases.Several of the cases of doctors mentioned in this reportcould serve as examples.

President Aquino has already laid the framework forintroducing human rights education as an integral partof the nation's educational system. In July 1986, sheissued presidential memorandum No 27, requiring theteaching of human rights at all levels of education. Inan adjoining memorandum, she stated that the study ofhuman rights would become 'an integrated andindispensable part' of military and police training. Thememorandum specified that the continuance in officeof all police and military enforcement personnel 'shalldepend on their successsfully completing the coursesoffered' under the human rights educationprogramme.The constitutional commission charged with writing

a new plan of government also took human rightseducation seriously. The draft, adopted by a vote of44-2, followed the president's lead by stating that: 'Thestate shall enforce the teaching of human rights at alllevels of education, as well as in non-formal training topersons and institutions tasked to enforce andguarantee the observance and protection of humanrights'.The new constitution's bill of rights contains strong

protective provisions against authoritarian rule andabuses of personal security. One provision strictlyprohibits the practice of arbritary arrests in the absenceof a lawful order of a court or as provided by law, andthe use of safehouses or unofficial detention centres.Another stipulates that: 'No torture, force, violence,threat, intimidation or any other means which violatesthe free will shall be used ...' against any person undercriminal investigation. The charter also bans the use of'physical, psychological or degrading punishmentagainst any prisoner or detainee or the use ofsubstandard or inadequate penal facilities under sub-human conditions'. It instructs the national legislatureto provide penal and civil sanctions for human rightsoffences, as well as 'compensation and rehabilitation ofvictims of torture or similar practices, and of theirfamilies ...'. The bill of rights also abolishes the deathpenalty and provides sentences of life imprisonmentfor prisoners already facing the death sentence(numbering about 650).One section of the constitution is devoted to issues of

social justice, 'to enhance the inalienable right to

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dignity'. Other provisions deal with land distributionand labour policy, agrarian and natural resourcereforms, the problems of the urban poor and housing,education, women, indigenous people, and 'thepeople's right to health'. Health care is to be promotedthrough a comprehensive programme that 'shall makeessential goods and social services available to allcitizens at affordable cost, with priority for the need ofthe disadvantaged, sick, women and children, agedand disabled'.Among the beneficiaries of the new constitution are

groups that monitor civil rights. In addition toguarantees of freedom of expression and association,the constitution provides safeguards for the 'right toinformation on matters of public concern', includingaccess to 'government research data used as a basis forthe policy development ...'. In an apparent recognitionof the February Revolution, the constitution states: 'Inthe pursuit of the ends of social justice, the state shallrespect the independence and the role of people'sorganisations as a principal means of empowering thepeople to pursue and protect through peaceful meanstheir legitimate and collective interests andaspirations'.

Throughout the process of drafting the newconstitution, commission members sought outsideviews regarding certain provisions. For example,Commissioner Minda Luz Quesada enlisted theparticipation of several health task forces to provideher with a series of 'concept papers' on health policy.Published by the Health Action Information Networks(HAIN), the papers examined a wide range of healthissues including public health education at thegrassroots level, the cost-effectiveness of existinghealth services, and the exploitation of health careconsumers by national and foreign drug companies.According to Commissioner Quesada, HAIN's'participation in research' efforts directly influencedthe content of the social justice provisions of theconstitution.

Conclusions and recommendationsTHE RIGHT TO HEALTH

Article XIII, 1, of The Philippines Constitution of1987 provides that 'the state shall adopt an integratedand comprehensive approach to health and other socialservices available to all people at affordable cost. Thereshall be priority for the needs of the underprivileged,sick, elderly, disabled, women and children. The stateshall endeavour to provide free medical care topaupers'. In effect, this article maintains that the rightto health is a state responsibility.What remains to be seen, however, is the extent to

which The Philippines medical community and thenew National Assembly will act to fulfill thisresponsibility by closing the gap between availablemedical knowledge and services on the one hand andtheir application and delivery on the other. To thisend, we wish to underscore several general precepts

and to make specific recommendations which webelieve should be taken into account in the nationaleffort to bring health care to all those in need.

1. We suggest that new incentives be developed toensure that doctors, nurses, and paramedicalpersonnel respond to the health needs of underservedpopulations, especially the rural and urban poor andtribal peoples. The aim should be to direct both healthpersonnel and services to geographic areas in greatestneed. Such incentives could include: pay benefits forhealth personnel who choose to minister tounderserved populations; requirements at theuniversity and vocational level aimed at sendingstudents in the medical and health sciences to work inareas where health services are unavailable, andscholarship programmes that would encourageFilipinos in underserviced areas to receive training inbasic health skills. Furthermore, high priority shouldbe given to developing public policy and educationalefforts to stem the high migration of Filipino healthprofessionals to other countries.2. Since planning for the health needs of ThePhilippines requires reliable information, adequateresources should be provided and methods developedfor the collection of accurate epidemiological data andinformation on health conditions throughout thecountry. In addition, non-governmental health groupsshould be encouraged to evaluate official health dataand to make their findings known to the generalpublic.3. Government health programmes should bedeveloped to educate Filipinos about the basicprocedures for identifying certain diseases so thatpatients can be referred to clinics and hospitals.Church-based and other private community healthprogrammes have made significant advances ineducating the rural and urban poor on such matters,but their resources are limited. The national mediacould play an important role in educating the publicabout health hygiene. University journalismdepartments, for instance, could develop writingprogrammes in conjunction with public healthdepartments to train both health professionals andjournalists in the most effective means ofcommunicating basic health information to the generalpublic. Television and radio could devote more airtime to the coverage of health matters and thepresentation of educational programmes on healthcare.

THE PROTECTION OF HEALTH PROFESSIONALS

During the Marcos years, many Filipino doctors andhealth workers were fearful of speaking out againsthuman rights abuses. Public criticism of thegovernment, particularly during the martial law years,often resulted in the loss of a promotion, a job, orimprisonment. To be sure, some health professionalsprofited from the government's emphasis on urban-based tertiary-care facilities and chose to remain

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50 Medical professionals and human nrghts in The Philippines

'apolitical'. Others openly criticised the government'sfailure to develop primary health care programmes orprotested violations of human rights and, in somecases, suffered reprisals for doing so.

Several provisions of the new constitution providefor the protection and promotion ofhuman rights. Thebill of rights states: 'No person shall be deprived of life,liberty, or property without due process of law, norshall any person be denied the equal protection of thelaws'. The charter also provides for the creation of 'anindependent office called the Commission on HumanRights' to replace the PCHR. The commission isempowered to 'investigate, on its own or on complaintby any party, all forms of human rights violationsinvolving civil and political rights'. Similarly, it will'exercise visitatorial powers over jails, prisons, ordetention facilities'.

THE ETHICAL AND SOCIAL RESPONSIBILITIES OFHEALTH PROFESSIONALS

Filipino health professionals and private health groupsconcerned with human rights deserve special credit fortheir public service. The MAG and its project forrendering medical care to torture victims, thePhilippine Action Concerning Torture (PACT), hasbegun to enunciate the elements of a new service-oriented philosophy for health care providers. But themomentum gained by MAG and other groups will needto be sustained through collaborative efforts withuniversity medical and nursing faculties, professionalassociations and government health agencies. Webelieve there are several steps that could be taken tofurther the training of health professionals in theirprofessional duties and responsibilities.

1. Professional ethics curricula for health careproviders should be developed to incorporateinternational standards for human rights. The 1978UNESCO guidelines for human rights teachingprovide several suggestions for inclusion of humanrights norms in university and vocational schooltraining, including the use of indigenous case studies.Curricula could include, for example, the examinationof such issues as child abuse and torture, practicesgenerally hidden by their perpetrators. Course workcould begin with class discussions about the nature ofthese abuses. How are they similar or different? Andwhat are the moral, ethical, and legal responsibilities ofhealth care providers in bringing these abuses to theattention of the medical community and the

authorities? Several other human rights and ethicalissues could be discussed, including questionsconcerning doctor/patient-prisoner confidentiality aswell as human experimentation in prisons.2. Developing curricula on human rights and ethicalmatters and providing treatment to victims of humanrights abuses need not be costly undertakings, thoughthey will likely require support from national andinternational foundations. We believe foundationsconcerned with health and human rights shouldcontinue to provide funds to projects such as PACT.While the human rights situation has improvedsubstantially in The Philippines, there remains a needto change the infrastructures that permit violations ofhuman rights to take place. And, as is often the case,those groups with the will and expertise to initiatechange lack sufficient financial support to do so.

It is difficult to be sanguine about stopping egregiousviolations of human rights worldwide. But, as theFilipino people demonstrated in February 1986, themobilisation of public opinion and pressure can beeffective in ending a heinous past. And, as Filipinohealth professionals have shown, individual andcollective action on the part of concerned professionalscan make a significant contribution to upholdingpersonal freedoms and social justice. The FebruaryRevolution was a historical landmark in non-violencewhich brought new hope to the Filipino people and toall those concerned with protecting and promotinginternational human rights. Similarly, the PhilippineConstitution of 1987 contains some of the mostprogressive safeguards for human rights of any charterin force in the world today. These initiatives haveplaced The Philippines on an exemplar path which, inthe field of human rights, could be one of worldleadership.

AcknowledgementThis paper is largely based on a book I co-authoredwith Professor Richard Claude and Eric Stover, HealthProfessionals and Human Rights in The Philippines,which was published by the AAAS, Washington DC,1987.

Dr June Pagaduan-Lopez, MD, is a Psychiatrist in theDepartment of Psychiatry, the University of ThePhilippines, Philippine General Hospital MedicalCentre, Taft Avenue, Manila, The Philippines.

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