This is Part II of a special series for Global Health NOW by Ana P. Santos, an independent journalist based in Manila, Philippines, featuring photography by Amanda Mustard. Read Part I, Elderly Mothers Bear the Emotional Burden of the Philippines Drug War, here

MANILA—While raising her 7 sons, Cora Enriquez, 60, lived amid a rambunctious tangle of chaos and boyish affection. Her sons were deeply protective of their mother, who is now a widow.Enriquez relished how they doted over her and, like many mothers, often recalls stories of their misadventures growing up with a wistful chuckle.“They would fight among themselves, but whenever one was bullied, all the others would rise to his defense.”

Mornings are quieter now for Enriquez, who lives alone in a small shanty in a slum community near the Navotas fishing port, where she scales buckets of fish for about $3-$5 a day.

She lost 3 of her sons years ago; they died of natural causes. Of her remaining sons—Itong, Mack-Mack and Arman—two are currently in jail; the other was only recently released.

Her youngest son, Rodzon, was the last one to leave the nest; he supported his mother by fishing. He went away to sea for days at a time, but would always return with some money and take his mother out to eat at Jollibee, a popular fast food chain.

Rodzon had just returned from a fishing trip and was resting when he was shot dead in anti-drug police operations in 2016 as part of President Duterte’s War on Drugs campaign. Human rights activists say that more than 20,000 people have been killed in a mix of police operations and vigilante killings of this drug war. Most of those killed are poor young men like Rodzon.

“He was asleep. He was tired from fishing. I told the police that there was no one home. I should have told him to run.” Enriquez plays back the scene over and over in her head, trying a different version of “if only” but always comes up with the same ending: Rodzon is dead.

“The natural order of events in one’s life is that the parent dies first. The disruption of this natural order can be devastating and traumatic. It does not happen frequently, so modeling from society on how to cope is lacking,” said Isabel Melgar, a psychologist and board member of the Psychological Association of the Philippines.

There are very limited studies on elderly grief in the Philippines, but Melgar says that mothers like Enriquez bear an exquisite kind of pain. “The death of their sons is already a tragedy. Then there are other feelings like frustration, guilt and injustice. It is an awesome burden to carry.”

While everyone has different coping mechanisms, stressors like poverty and abrupt, violent deaths of loved ones can impair the healing process.

Carmelita Bajacan also lost a son to the anti-drug wars in the Philippines; here she holds a family photo. Image by Amanda Mustard for Global Health NOW.

“The kind of family support we have, our physical health and our own individual experiences all affect our ability to cope with bereavement,” says Jasmine Vergara, a mental health expert at the WHO in Manila. But generally, she adds, older people are less resilient.

“There are normal stages of grief like bereavement, acceptance and adjusting to life without your loved one. If these stages extend beyond 6 months, it is considered complicated grief or prolonged grief disorder,” she says.

This is when the emotional pain is so severe that a person finds it difficult to do the things they would do on a daily basis like getting dressed, sleeping or even maintaining proper hygiene.

According to Vergara, it is important to differentiate between typical reactions to grief and prolonged grief disorder.

However, that isn’t always possible in the Philippines, where recognition of mental health is still in its nascent stage. In 2004, the Department of Health reported 4.5 million cases of depression. Currently, there are only about 600 practicing psychiatrists for a population of more than 100 million people spread out across an archipelago roughly the size of Arizona. Mental health services are a luxury.

Until the Philippines enacted a mental health law last year, it was one of the few countries without a legal framework to provide mental health services.

One of the new law’s provisions is to train more health care professionals at rural health centers to recognize the symptoms of depression and grief and seek proper intervention. It is a small but concrete step in the attempt to lessen the stigma of mental health and make mental health services more accessible.

The implementation of the law will be another matter, and though elderly mothers grieving the death of their sons need mental health support, so much of their daily life is consumed just trying to survive; mental health and emotional support is not a priority.

Counseling sessions run by religious organizations and other groups help fill in the gap. Flavie Villanueva of the Society of Divine Word runs a small but intensive 4-month program called Hilom (Healing) which covers counseling, legal advice, and livelihood assistance. Villaneuva says that he sees a difference in the mothers who have completed the program. “They still want justice. But they are less angry and are ready to forgive themselves.”

Enriquez has not taken part in the Hilom program, but seeks out alternative forms of comfort. Caring for her dog, Cuchay, and her puppy Bantay (which means “guard”) help fill the hole in her heart left by Rodzon’s passing.

She also visits her sons in prison when she can. Arman had not yet been detained when Rodzon was killed. He recalled watching his mother become withdrawn, despondent and angry. He often wondered if she blamed him for his brother’s death.

Asked about this later, Enriquez shook her head and said, “I wasn’t mad at Arman.” Biting down on her lower lip, Enriquez began to cry. “I was mad at myself. I don’t think I’m a bad mother but why did this happen to my sons? What did I do that was so bad to deserve all of this?”