By Marilou Guieb
Over a hundred years ago, when tuberculosis (TB) was ravaging the country, many of the afflicted were sent to Baguio, then known as Kafagway, to recover. It was believed that the pristine environment and clean air, lots of vegetables and fresh fruits, would be the key to a cure.
In fact, the now Baguio General Hospital started as a sanitarium for TB patients in advanced stage.
But the clean air as a cure turned out to be a myth, as unknown at that time, TB is really caused by a bacterium called Mycobacterium tuberculosis, which usually attacks the lungs but can also attack other organs such as the kidneys, spine and brain. While clean air and healthy foods boost health in general, TB, a patient under modern day treatment is given drugs depending on whether he has drug susceptible TB or drug resistant TB.
There are three types of TB, namely: Active TB where the TB bacteria are rapidly multiplying and invading different organs of the body; Miliary TB, a rare form of active disease where the TB bacteria enters the bloodstream; and Latent TB infection.
Now a hundred years later, TB is still a global threat, so much so that it was included in the SDGs as under End TB strategy with a target of 2030 for achieving the goals. These include an 80 percent reduction in TB incidence (new and relapses) per 100,000 population per year; 90 percent reduction in annual number of TB deaths compared with 2015 by 2030: (2020 milestone- 35 percent reduction), (2025 milestone – 75 percent reduction) ; and no household affected by TB to face catastrophic cost by 2020.
How grave is the problem? In 2019, 10 million people were diagnosed to have TB, with 8.2 percent among them having HIV too.
Among eight countries that had at least 100,000 incident cases of TB in 2019 that accounted for two thirds of global cases, the Philippines ranked fourth, accounting for six percent ( India – 26 percent; Indonesia – 8.5 percent; China – 8.4 percent; Pakistan – 5.7 percent; Nigeria – 4.4 percent; Bangladesh – 3.6 percent; and South Africa – 3.6 percent).
From 2015 to 2020, the global reduction rate was pegged at 20 percent, and in 2019, the reduction was nine percent. In terms of deaths, the target was 35 percent reduction, but with only a 14 percent achievement rate by 2019. It’s a grim picture, translating to TB as leading in infectious diseases and one of the top ten causes of death, numbering 1.4 million deaths, 208,000 among them with HIV.
TB can wipe out a family’s income and with a global target of zero cost by 2020, 49 percent of people with TB still faced catastrophic costs.
While the number of TB cases notified has increased and deaths have decreased and despite more people under preventive therapy, it is far from the milestones hoped to be achieved by 2020.
In the Philippines, the Department of Health has come up with a National Tuberculosis Control Program. The approach is a patient- centered tuberculosis care which ”recognizes and respects the patient’s rights and values, considers the patient as an important partner who actively participates in decisions on diagnosis and treatment.” This includes respect for patient autonomy; maximizing physical comfort, safety and wellness; provision of psycho-emotional support and protection from social isolation and discrimination; financial assistance to support diagnosis and adherence to treatment.
The Philippine TB burden rate, per DOH records, show incidence rate to be stable at 554/100,000 since 2016 and a decrease in deaths per year since 2000, and 35 percent of TB patients still facing catastrophic costs in a 2017 survey. The next survey will be in 2022.
For the Philippines, the WHO said that the 554 cases per 100,000 population is the highest TB incidence in Asia as of 2019. About 74 Filipinos die of TB every day and like globally is among the top ten causes of deaths.
COVID-19 and TB – an alarming scenario
And the situation is sadder with the DOH National Tuberculosis Control Program reporting 88,662 new and relapse cases from January to March in 2019, or a steep decline by almost 20% between February (30,728) and March (24,782) as a direct effect of quarantines and theCOVID-19 pandemic According to DOH data, approximately 268,816 new and relapse TB cases were notified to DOH by the end of 2020, a 35% decrease from 2019 data. . One TB case undetected would mean ten more people getting afflicted.
And if the trend continues, Over 100,000 Filipinos may die of tuberculosis (TB) in the next five years or 20,000 TB deaths per year if TB services continue to be disrupted because of mobility restrictions brought about by COVID-19.
The DOH NTP 2020 report says three Filipinos die of TB every hour. Imperial College of London in a model, projected between 65,100 to 146,300 TB deaths may happen if the COVID-19 fears continue to limit local TB services in another year remain limited in another year.
“We see this as a direct effect of the COVID-19 pandemic on a critical disease prevention and control program like TB,” said Health Secretary Francisco T. Duque III. “The quarantine has extremely affected and limited the health seeking behaviors of our fellow Filipinos,” he added.
The Cordillera TB scenario
Leahlyn Salud Badongen, NTP nurse coordinator for the Cordillera Adminstrative Region, in her report said that in 2020, they had a recorded registered cases of 1205, with 706 having completed the treatment and 398 cured. 36 died of the disease.
Mirroring the national scenario, Badongen said that lockdowns and border controls have limited their monitoring because while drugs and medication were given weekly before the pandemic, this has changed to monthly supplies.
Of the 1205 cases, she said that Baguio had the highest number of cases ( 273) and Mountain Province at 87. While it was expected that remote areas would be the most problematic in terms of cases notified and treatment, she said that it wasn’t really the case as the rural health centers are well spread out. In some areas, seeking medical treatment entails crossing rivers, and for the very sick, practices like the Ayod of Ifugao remains in practice. This is carrying a patient in a hammock over hills and across rivers. The practice persists in some other far and isolated areas in the region.
“Access is not really the problem,” she said. She pointed out more to patients not fully understanding or appreciating treatment methods. “We follow a patient choice approach’” she said, and added that they are pouring greater efforts in communicating to patients the importance of the drugs in the treatment. “There are some who are discouraged because of temporary effects like nausea or vomiting, so there is a loss in follow-ups.” she added. Under, the DOTS treatment or “Tutok Gamutan,” patients need to have a kind of “buddy system” which means that there must be somebody to endure that the patient gets the drug regularly so as not to develop resistance. This entails a treatment of six months for drug susceptible TB.
Even longer is the treatment for drug resistant TB patients which can stretch for nine to twenty months. The duration alone can make a patient fail compliance.
Baguio’s high incidence, while it may also be due to denser population, she said may also be due to closer people interactions and congestion. TB is airborne and spread through droplets and in a crowded place will have more people prone to getting infected.
The region, mostly inhabited by indigenous ethnic groups, also have a high regard for their own ethnic cures which may alter health-seeking behaviors. In some areas, illnesses are still regarded as having displeased the spirits or nature guardians and resorted to rituals invoking the mercy and benevolence of the spirits and ancestors for a cure.
Given all these factors, where is the Philippines headed in terms of its TB control program?
In September of 2018, Duque committed to find and treat 2.5 million Filipinos with TB at the United Nations High Level Meeting on TB in New York City, a DOH release reported. Since then, the DOH has recorded 1.1 million TB cases, leaving 1.4 million more cases to find and treat until 2022. As of 29 August 2021, data from the National TB Control Program showed that TB cases notified to the DOH stood at 340,524, or just about 14 percent of the 2.5 million target by 2022.
A release by DOH also said that estimates, because of the pandemic, notified cases in 2020 will only reach 72% of the annual target. By the end of 2022, if this trend continues, the Philippines will miss its commitment by almost 300,000 cases.
DOH also said that TB is curable and treatment is free in public health facilities nationwide.
But there are still those, and perhaps a greater number, would do nothing or self- medicate. In the mountains of the tribes, there are the spirits to turn to. And prevalence of these behaviors may get stronger because of COVID-19 restrictions.
Take note then, a cough may be a scare telltale symptom of COVID-19. But a cough of more than two weeks may be that silent killer, TB. So, there is everything to gain and a life well lived longer if one can just think that it may just be TB and cure is just a visit to a health center away.
This story supports the #TBFreePH campaign of the Department of Health (DOH). With the help of the United States Agency for International Development (USAID), #TBFreePH aims to increase and improve conversations about TB and help address stigma and discrimination experienced by persons with TB.