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GO-MED: The Baguio Mission Video

GO-MED: The Baguio Mission from Baby Seal Films on Vimeo.

The way I usually make a video is that I shoot everything and hope that I can cut it together into some kind of story afterwards. There actually isn't a lot of planning involved. When interviewing people I might have scratched down four or five questions beforehand, and then sometimes I forget to bring my questions. And then there is quite a bit of time spent setting up the shot and getting people wired for the sound. So my subjects, Dr. Peter Blair, Betty Allan, and Danielle Delves, deserve a lot of thanks for their participation in this video. You accept a huge responsibility when someone entrusts you with their moving image. I can think of probably dozens of ways you can make someone look bad and far fewer ways to make them look good.

Katya did a lot of shooting during the day and when I was done with my case list we would look for someone and somewhere to interview. The operating room I worked in during the first week had amazing natural light. One wall was made up of frosted windows, so it was perfect to shoot in. We did our first interview with Dr. Blair there. Unfortunately, later on when we wanted to shoot in it the GYN team was operating in it. I really wanted to record all the interviews in the hospital because Baguio General is such an interesting facility, but it was difficult to find locations that were reasonably private. We also had serious issues with ambient noise, such as chatter and air conditioners.

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The short clips are a small part of the interviews we recorded, and a lot of good material was left out. It is amazing what you can find out about someone in a formal interview, stuff that wouldn't come out in everyday conversation. I probably wouldn't have known how passionate Dr. Blair was about the problem of poverty (not only in the Philippines but in Canada as well) for instance, or the story Betty told about the kid with burns (that happened during a previous mission, by the way). One thing I learned is that people tell some of the best stories when the interview is over and camera has been turned off. Next time, I plan to keep the camera running after I've announced that we are done.

As far as the equipment we used, we had a Canon Vixia HF M31 camcorder, and a Canon Rebel T1i EOS 500D. The Rebel shoots HD at 1080p 20 fps, but focus is only manual in video mode. Katya also used her point and shoot Nikon which shoots in HD. We used a prime 50 mm 1.4f lens for the interviews, which works really well for shooting indoors with natural light, and a Zoom H1 portable digital voice recorder attached to a tiny lavalier mic for sound.


In Search of the Filipino Barrel Man

Baguio Market from Baby Seal Films on Vimeo.

I’m not much into souvenir shopping. I do enjoy browsing gift shops but I don’t bring home a lot of gifts. For one thing, I don’t like haggling or the feeling of being ripped off. For another, in the age of globalization, there is very little that is truly unique that you can’t buy off the internet if you really want it. And when you do find something interesting, you can’t be sure if it was made by a local artisan or mass produced in Fujian, China. In Mexico, for instance, shop vendors would tell me that that their “Maya Calendars” were hand carved by their brother, when it was obviously made out of resin poured into a mold, and looked exactly like a hundred other calendars everyone else was selling. I don't understand how they were able to make any money when everyone else was selling the same stuff, probably purchased from the same Chinese manufacturer.

My father works for Holland America as a cruise ship doctor, and my parents have spent a lot of time cruising around the world. My mother said that in the ports in the Caribbean the gift shops would be selling the same gifts and jewelry that were being sold in Alaska. It’s as if the cruise ship companies or their affiliates built these quaint little towns from the ground up, complete with a Pizza Hut and KFC, just so that the tourists would have a place to get off the boat and shop. None of the products for sale are actually locally made and there is no sign of any thriving indigenous culture.

What makes a good souvenir anyway? Do you look for something useful, creative, skillfully made, or entertaining? I imagine that people value uniqueness and a connection to the country they are visiting, and preferably something made by local artisans. It’s good to know that your purchase supports the local people and industry. For instance, I was a little disappointed when I bought a stuffed toy lizard in Maui for my daughter, only to find out later that it was made in Seattle. The degree of difficulty in the acquisition of an object is important too; it kind of deflates the excitement when you realize that the perfect gift item you found in a tiny store in the mountains of the Philippines is readily available at the Cost Plus World Market import store close to home. You can thank globalization for making souvenir shopping a little more challenging.

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Katya and I expected that some of the best shopping would be at the Baguio City Market. A sprawling and labyrinthine area, it is hard to tell where the market begins and ends. Countless small shops are hidden off dark narrow pathways. With the exception of the meat section, the fish section, and the fruit and veggies section, they all seem to be selling the same things: canned goods, local peanut brittle, woven purses, native textiles, brooms, wooden carvings, penis ashtrays, and of course the filipino barrel man.

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The filipino barrel man is one of the most famous souvenir items from the Philippines. It is small carved wooden figure of a man standing inside a barrel. If you pull the barrel up, his oversized penis springs out, fully erect! Like the giant wooden fork and spoon wall hangings, it is unquestionably filipino.

I’ve been searching the internet about the history of the barrel man, and unfortunately there is very little written about him. He originates in the Cordillera highlands around Baguio, but can be found all over the Philippines, even in high end gift shops in Manila around Ford Santiago, as well as the International Terminal of Ninoy Aquino International Airport. He is assumed to be an Igarot man. The carving is crude and lacks details, however, and you couldn't tell he is Igarot from his clothing -- he’s naked! It is only clear that the man has long hair and is wearing a head band.

The asking price for the barrel man in Baguio is about 100 pesos, which is a real bargain, considering that at the gift shop in Intramuros in Manila it is selling for 360 pesos (but since everything in that shop was permanently half off, they were really asking 180 pesos). That is only for the smallest sized barrel man. They come in various sizes and the larger sizes go for more. I found a large barrel man for sale on eBay for as much as 74.99 USD (“Buy It Now”). Maybe this puts the value of the barrel man into the proper perspective. Or it only shows that the only people selling anything on eBay these days are opportunistic resellers.

All of the modern barrel men look exactly the same, which suggests that they are all made in the same factory, or maybe in a few factories under the same management. But I was able to find a number of different iterations of the barrel man for sale searching for "vintage filipino barrel men" online. In one, the figure is more realistic and the features are more refined. Another one looked very old. The figure was highly stylized, and only abstractly resembled a human form. Unlike the modern version, the arms of the figure do not spring out, but are folded across the chest. The wood is dark, almost black, and there are white designs painted on the barrel. Could this be an early version, perhaps a prototype, one of the very first filipino barrel men?

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Another interesting item we found was the cane toad purse. It is the body of a real toad that has been tanned and fashioned into a small purse, usually with a zipper across the chest and an added shoulder strap. It’s a unique accessory, complete with plastic googly eyes where the real ones used to be. The cane toad is not native to the Philippines but was brought there in 1930 to control pests in the sugarcane fields. It subsequently became the most ubiquitous amphibian in the islands. So these cane toad purses definitely could be made locally. I am suspicious though because identical cane toad purses are being made at The Toad Factory in Australia.

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Other unique items are small purses made out of recycled juice containers (made by the Womens Multipurpose Coop in Baguio), the famous Baguio peanut brittle, and wooden hand-shaped chairs. By “hand-shaped” I don’t mean “shaped by hand”, but rather “shaped like a hand”. The hand-shaped chair design I suspect is not native, but instead was inspired by the surrealist Mexican artist Pedro Freideberg, who first started making hand-shaped chairs in 1962.

The other item I thought was uniquely filipino is the hand-carved highly polished wooden penis ashtray. When I was a kid decades ago, I saw them in Baguio at the gift shops around Mines View Park. There were tables covered with rows and rows of them, many more than you see these days and out front where passers-by could easily see them. It is something that you don’t easily forget. I had assumed that they were a sacred fertility symbol of the Igarot, the mountain people, central to their animist religion. I didn’t even know they were ashtrays!

Apparently you can buy wooden penis ashtrays in Bali that look exactly like the filipino ones. What surprises me is that the penis ashtray is a well-known Bali souvenir. So what is the provenance of the penis ashtray? Did it originate in Indonesia or the Philippines? The fact that I’m asking the question means that the value of the penis ashtray as a souvenir has been hopelessly degraded. It is no longer uniquely connected to a particular people or place. Years ago the penis ashtray meme must have made its way from one tourist destination to another, and a local artisan thought, “I can make this and these stupid foreigners will buy it!” Now it's just a funny ashtray mass-produced for tourists, devoid of any cultural significance. They might as well be selling them in gift shops in Mexico or the Caribbean.


Panagbenga

Panagbenga: The Children's Parade from Baby Seal Films on Vimeo.

We were lucky to be in Baguio at the time of the start of the annual flower festival, known as Panagbenga. “Panagbenga” is a Kankanaey term that means "a season of blossoming, a time for flowering". The month-long festival was created as a way for the city to rise up from the devastation of the 1990 Luzon earthquake. It starts with a parade of elementary school kids that runs through Session Road downtown and ends in a street dancing competition at the Athletic Bowl. The children come from all over the region, riding in on jeepneys. The staging area happened to be on South Drive, right next to Ating Tahanan. We were advised that no taxis would be running in the morning, and to leave for work early that day because the street would be crowded. Everyone wanted some extra time to enjoy the spectacle in the staging area anyway. Katya and I decided to take the entire day off to see the opening parade and festivities in Burnham Park downtown.


Our Single-Use, Disposable Culture

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Empty operating room at Baguio General Hospital

A favorite topic when discussing working in the Philippines with medical people in America is “how bad things are over there”, referring to the the limitations on supplies and equipment as well as the weirdness of the pathology. I like to reply with, “It was really bad. They wash and reuse gloves!” Then I like to show them pictures of the rusty chairs and equipment that looks like it was left over from the 1960s. Those kind of stories make us in North America feel fortunate that we have the latest equipment and technology at our disposal. We can all be proud of the health care industrial complex that we have built! But those stories also highlight the ingenuity of people when challenged to work with the limited resources in developing countries.

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Sterile surgical instrument set, covered with reusable cloth.

 

THE SINGLE-USE, DISPOSABLE CULTURE

One way to contrast the two medical systems is to focus on the use of disposables. If you are the type of person who cares enough about the environment to recycle, shop for groceries using canvas bags and avoid buying bottled water, you would think the amount of medical waste we generate in this country is obscene. Health care produces a massive amount of garbage, and operating rooms and labor and delivery suites together produce the largest fraction of it --  70% of a hospital’s waste. It is not all paper drapes and plastic containers, but also includes highly engineered, precision instruments. There are a number of reasons for this. There is a trend to make everything single-use and disposable. Prepackaged, single-use instruments guarantee sterility and quality. Also, hospital infection control committees have increased efforts to totally eliminate any risk of hospital-acquired infections, especially methicillin-resistant staphylococcus aureus (MRSA). They do this by making sure nothing that touches a patient gets reused, especially when used on patients who have had any history of MRSA. I also can’t help but wonder if the profit motive also influences the decision of medical equipment manufacturers to push single-use disposable devices as well. 

A list of the devices in anesthesia practice which used to be reusable and now are routinely individualized and disposable includes pulse oximeter probes, blood pressure cuffs, EKG cables, laryngeal mask airways (LMAs), patient gowns, towels, surgical table covers and linens, arms restraints, and Hovermatts (a inflatable mattress used to move extremely obese patients -- an increasingly important piece of equipment these days). Someone must have calculated that it costs more to wash, process, and resterilize all this stuff, especially when short-staffed. Many anesthesia technicians and nurses I have spoken with about this issue actually prefer disposable equipment because they don’t like having to clean dirty equipment, especially if it is something covered with blood or secretions. Even after my hospital contracted with a medical recycling company to clean and reprocess this stuff, the nurses would still throw them away rather than toss them into the recycle bin.

In my hospital, we are not allowed to use injectable drugs from one vial in more than one patient, even if the drug vial states that it is intended for “multiple use”. This is ostensibly to prevent cross-contamination from one patient to another, although this is easily avoided if you simply don’t use a dirty syringe to draw up your medications. The real reason has to do with accounting and billing: pharmacies can charge a patient for the cost of an entire vial, but can’t charge multiple patients for the cost of a fraction of the drug taken from one vial. We are supposed to dispose of any unused medications, which means that a lot of half-filled vials of expensive drugs get thrown away. The exception to this has been whatever drug of the week is currently in critically short supply, then we are allowed to save the unused portions of that particular drug.

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Surgical instruments are also totally disposable now too. Manufacturers say having prepackaged, sterile equipment helps expedite the device preparation process. They argue that reusable instruments have hidden costs: instrument repair, the labor associated with cleaning and sterilization, and OR time lost because of instrument failure. With prepackaged, single-use instruments the cost of cleaning and sterilization is eliminated. Probably more importantly, like with drug vials, it is easier to track the cost of the instrument and pass that on to the patient.

There is a hidden cost to single-use instruments too and that is cost of disposal, not to mention the environmental impact, a cost that is passed onto the public. There are also human costs. Most single-use stainless steel surgical instruments are manufactured in factories in Pakistan and undergo final finishing and quality control in Germany before being shipped throughout North America and Europe. Since Pakistani factories only pay their workers $1 for a 12 hour day -- less than a living wage -- they rely heavily on child labor. 

In contrast to single-use instruments, high quality long-lasting German made steel surgical instruments intended for repeated use can be re-sterilized and reused about 3000 times. Although the initial cost and carbon footprint is greater, with repeated use the overall cost and environmental impact is much less compared to single-use instruments. But for reason this doesn't seem to make financial sense anymore. 

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REDUCE, REUSE, RECYCLE

On our mission we had to make the most of our limited supplies and conserve our disposables as much as possible. I took inspiration from the resourcefulness of the locals. I didn't reuse my gloves, but I used the same anesthesia breathing circuit for a week, and just changed a disposable bacterial filter/humidifier at the patient end. The anesthesia mask, made for single use, was washed between cases, along with the disposable oral airway and non-disposable laryngoscope blade. I had a more than adequate supply of endotracheal tubes. These were donated because they were past their expiration date or the packages had already been opened; it is common practice to open sterile equipment before an operation to save a few seconds, and not use it.

To conserve needles and syringes I mix drugs in the same syringe and deliver them concurrently, such as ondansetron and dexamethasone. Before doing this it is important to consult a compatibility chart to see whether they are truly compatible. Lack of visible precipitation alone is not evidence of compatibility.

We used facemasks folded over and tied around the patients arms as arm restraints, and used the same pair all week. In the United States our containers for hazardous sharps waste are single-use and specifically manufactured for that purpose, with a lot of safety features (colored red, with a lid that automatically prevents overfilling and locks down for final disposal). Instead we improvised with empty plastic IV bottles with a hole cut on the top.

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Improvised sharps container

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THE PROBLEM OF HYPOTHERMIA

One problem that we could have dealt with better is intraoperative hypothermia. You would think this might not be a problem in a tropical climate, but since Baguio is over 5000 feet above sea level the weather is usually cool and we also kept the operating rooms is air-conditioned. A patient's drop in core temperature in the first hour of surgery is primarily due vasodilation produced by the induction of anesthesia. Vasodilation redistributes heat from the core to the periphery, and the only way to prevent a drop in core temperature is to actively warm the patient for about an hour before surgery. Additional heat loss during surgery is caused by conductive heat loss by contact with the OR table, radiative loss from exposed skin, irrigation with room temperature solutions (into an open abdominal cavity for instance), infusion of room temperature IV fluids, and ventilation with cold, dry gases. On arrival to the recovery room, we had patients as cold as 33.2 degrees C. Hypothermia is not only uncomfortable for patients; it also slows emergence from anesthesia, increases oxygen consumption by inducing shivering, inhibits coagulation, suppresses the immune system, and increases the risk of postoperative wound infection. If severe enough, it can cause life-threatening cardiac arrhythmias.

Unfortunately, we lacked any practical, effective means to prevent intraoperative hypothermia. The best way is to use a forced air warming system, which works by blowing hot air into a single-use, disposable inflatable blanket. Imagine turning a big hair dryer on "high" and blowing it underneath a blanket -- toasty! Even regular blankets were hard to come by. After some discussion with the recovery room nurses, the surgeons agreed to turn the air conditioner off in the OR. They suffered under the hot gowns and had to have nurses wipe their brows, but the patients came out a little warmer.

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The BGH recovery room nurses use an improvised radiant warming device, which is a single lightbulb surrounded by a thin plywood shade hung over the patient. They let our team use them when there was enough to go around. I think the yellow light gave more of an impression of warmth than actual heat. It only used a 60 watt bulb.

The Canadian recovery room nurses put on knit wool hats (“toques”) on patients, and also came up with the idea of putting blankets and hats on our patients preoperatively to keep them from getting cold while waiting for surgery. For the next mission they are planning to bring a bigger supply of toques and socks to give to patients.

 

THE MONSTER

Remember the patient who had the the large dermoid cyst removed? I caught up with rounds on the gynecology ward just as they were seeing her on the first postoperative day. She looked very happy. She wanted to see pictures of the mass, which she referred to as her “monster”, so Katya ended up printing out pictures for her to take home with her. Our anesthesia coordinator Dr. Hoskin told me that all three of my patients from the day before were comfortable overnight. Despite only receiving Tylenol and ibuprofen the night before, the only thing that they complained about was discomfort from the urinary catheters, so the paravertebral nerve blocks we performed must have worked well. 

[Photographs copyright Katya Palladina]


Vegan Adventures in Baguio

Vegan Adventures in Baguio from Baby Seal Films on Vimeo.

Traveling overseas on a plant-based diet requires a little planning and resourcefulness. It’s good to request a special vegan meal for your international flight, for instance. For that you need to call the airline in advance, at least 24 hours before, or maybe it’s within 24 hours. I don’t remember exactly because honestly I don’t do it anymore. But when I do remember to do it I am usually pleased with the results. You get your food before everyone else and it is a much less greasy and more interesting choice than the usual "chicken or beef" smothered with cheese product that everyone else gets. The airlines purposefully make it difficult to find the telephone number to call to make your request, so these days I just deal with what everyone else gets but only eat the veggies. I will also carry-on my own food such as nuts, dried fruit, and LARA bars (which are basically nuts and dried fruit). Most of the time I just sleep as much as I can on the plane and skip the meals. Flying in economy is so miserable anyway that you don’t really want to be conscious for it. Essential gear: inflatable neck pillow, a beanie (toque if you are Canadian) to keep your head warm and pull over your eyes, and Ambien.

While we are on the subject of eating and flying, I should mention one weird trick discovered by a mom to compleletly cure jet lag in one day. Fast for 16-12 hours prior to the time when you want to wake up. You can drink liquids but nothing with any calories in it. Then have a big breakfast. The caloric intake overrides the control of the suprachiasmatic nucleus over your body’s diurnal rhythm and resets your biological clock. I will also use sublingual melatonin to go to sleep at night, about 1 to 3 mg. Using this technique we didn’t have any problems with jet lag at all.

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 Katya at Narita International Airport

When traveling I do allow myself some flexibility in eating. When in Peru, for instance, I couldn’t resist that chance to try cuy (guinea pig), or eat the sushi in Japan. That might offend some people who say that I’m cheating, being hypocritical or “unpure” or something along those lines. Whether I am or not depends on the reasons I decided to stay on a plant-based diet in the first place. For me it is primarily for health reasons, because there is a lot of scientific evidence that a whole-foods, plant-based diet can prevent and even reverse the progression of the most common chronic diseases. I am also concerned about animal welfare, and especially the effect of factory farming on the environment. Lastly, I am a little concerned about my carbon footprint. Not eating meat is the single most effective thing you can do to decrease your carbon footprint, even more effective than switching from a standard car to driving a Toyota Prius.

In developing nations, you take a risk of getting gastroenteritis from drinking tap water, or eating raw fruits and vegetables and street food. Filtered water was available everywhere in large jugs. I also brought my own Lifesaver bottle, which I could use to filter tapwater. It came in very handy when bottled water was scarce and you just wanted some to brush your teeth. (Yes, you should avoid brushing your teeth with tapwater.)  The Lifesaver filters down to 15 nm and produces sterile water. It filters out all microorganisms, including viruses.

The higher end restaurants might have washed their produce in filtered water. You could wash your own vegetables in filtered water, but that alone might not remove the biofilm. Sprouts and root vegetables for instance, are known to actually absorb surrounding soil microorganisms into their tissues, developing a commensal relationship with them. That’s one of the reasons eating spouts is risky, even in the United States. What if that lettuce was fertilized with raw human sewage? You could try adding a little bit of bleach to it but I don't know how effective that is. I would have to be really craving a raw salad to go before I go to that much effort. In general I just avoided eating any raw vegetables or fruits unless I peeled them myself.

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We were prepared to cook a lot so one of our first stops was the grocery at SM Mall. The kitchen at Ating Tahanan was equipped with pots and a wok, knives, and cutting boards, but we needed to buy cooking oil, soy sauce, spices and plastic wrap. We cooked mostly veggie stir fries and rice, tofu adobo, and that green mango/papaya salad I mentioned earlier.

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Raw green mango/papaya salad.

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The meals they served in the hospital were excellent. They provided us with breakfast and lunch, so there was always a buffet set out in the lounge, which was perfect for grazing between cases. We would get a lot of rice, grilled eggplant, okra, chayote and sayote greens, green beans, bananas, watermelon, mangoes, papaya, and strawberries, a specialty of the Baguio region.

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I was surprised at the vegetarian options as far as restaurants went. There is a place called Bodhi at the food court at the bottom level of SM Mall which served vegan versions of filipino dishes, a lot with some very convincing fake meat. There is another vegetarian restaurant on Session Road called Oh-My-Gulay! It is a little hard to find because the signs aren’t very good, and it is on the roof of a 5 story building and as far as I could tell only accessible by the stairs. The restaurant has two levels and a balcony, on one side looking across town to Burnham Park, and into a garden courtyard area with a fish pond on the other. The interior is really very interesting and worth the visit. The food was good, but the waitstaff seemed less than enthusiastic about working the day we were there, even though the restaurant was nearly empty. Also the bathrooms were a little sketchy and didn’t have any toilet paper.

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Don’t even bother going to Jollibee or Chow King; there is nothing at all to eat there, except maybe the fries at Jollibee if you are desperate. We shared a Super Halo-Halo at Chow King, because Katya wanted to try halo-halo and ube ice cream.

One of the Canadian nurses who knew we are vegan said that he saw some vegan sausages at the public market, which really surprised me, because we had been there, and didn’t see any. He showed me the picture he took on his iPhone. The sign actually said “Vigan” sausages, which in this case refers to a type of sausage made from garlic and pork that comes from the capital of the province of Ilocos Sur called Vigan. I think he really thought that they really were “vegan”, but i suspect the concept has yet to reach the filipino consciousness.

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In the video Katya describes how to eat like a Filipino with a fork and spoon. The kitchens of filipino homes are often decorated with a giant wooden fork and spoon. Filipinos eat with a spoon in their right hand and a fork in their left, and push the food onto their spoon with their fork. They don’t use knives but use the edge of the spoon to cut food. This is possible because the meat is usually prepared in small pieces instead of big slabs, and also cooked very well-done. The cooking style probably evolved to avoid rare meat because bacterial contamination was common in the warm climate.

In 2006 in Quebec, a Filipino-Canadian boy attending Grade 2 at Lalande School in Montreal's Roxboro district was repeatedly reprimanded by a lunch monitor for eating with a fork and spoon at the same time:

The boy's mother met with her son's lunch monitor, Martine Bertrand, after she told him that his habit of eating his noodles with both a fork and a spoon was disgusting.

Maria Gallardo said she explained that the practice was a tradition in the Filipino community, but that Bertrand was unwilling to compromise.

When Gallardo tried to meet with the school's principal to address the situation, Normand Bergeron dismissed the request and said her son should learn to eat like other Canadians.

Ultimately, Quebec's Human Rights Tribunal ordered a Montreal-area school board and two of its employees to pay a total of $17,000 in damages to the family of the boy for their cultural insensitivity.