THE OTHER WEEK, my housekeeper asked me if I could refer one of her friends to the Lung Center. The friend had come to Manila all the way from Samar with a very sick 19-year-old daughter. My housekeeper said the girl had difficulties breathing, had been coughing, and had swellings on both sides of the neck. From her description, I already had suspicions about what the girl?s illness was.
Eventually, I found out the girl had been brought to the Philippine General Hospital (PGH) where they quickly diagnosed her as having tuberculosis in a very advanced state, having been left untreated. The family had been asked to go to Jose Reyes Memorial Hospital, which is the government hospital for infectious diseases, but it couldn?t handle the patient either and suggested Quezon Institute, which specializes in tuberculosis.
It turned out, too, that the family was in denial. Back in Samar they had already consulted doctors and a diagnosis of TB had been made, but the mother was adamant, insisting it could not be TB. It didn?t run in the family, she said, and besides how could such a young patient, a girl at that, get that disease? Wasn?t TB a disease of older men?
As if matters weren?t complicated enough, the mother and other relatives had come up with their own explanation for this lingering illness: whatever the sickness was, it probably was brought about by barang or sorcery (kulam in Tagalog).
This case isn?t closed yet. My housekeeper says she has given up on that family as they continue to go around different hospitals. I suspect they will keep shopping around until they find a doctor who will not use the dreaded word TB.
The World Health Organization and the Global Fund to Fight AIDS, TB and Malaria (supported by large corporations) have poured millions of pesos into the Philippines to conduct educational and information campaigns about TB and to provide TB medicines for free. Yet, we continue to have one of the highest TB infection rates in the world. WHO?s 2009 Global TB Report estimates that we have about 440,000 TB cases. About 36,000 die each year from the disease?or almost 100 people a day.
I worked with TB programs between 1978 and 1985 with the late Dr. Mita Pardo de Tavera, who was a firm believer that TB was a disease of poverty. It?s the poor who are more vulnerable for many reasons: infants not getting their BCG vaccination, malnutrition, crowded living conditions. Our TB program included the free distribution of medicines, which were (and still are) quite expensive. The medicines were given under very close supervision, with daily visits to make sure the patients were taking the medicines. The WHO and our Department of Health have since adopted a similar program called DOTS (direct observed therapy, short-term), which requires patients to take the medicines in front of a health personnel.
But the TB program has continued to fester through the years and I?ve come to realize that while poverty plays a major role in TB?s spread, there?s a cultural ?hard core? to TB which is not limited to the poor. For example, the family of the 19-year-old girl from Samar is middle-class, able to afford coming to Manila and to ?shop? around the different hospitals. I wonder at times if TB might be even more deadly with the middle and upper classes, where denial might come about because TB is seen as a disease of the poor.
Let?s go back to barang first. Even upper-class Filipino families have been known to bring in traditional medical practitioners to conduct kontra-kulam rituals.
Sorcery thrives on people?s fears. Patients themselves might not believe in sorcery but if people around them keep talking about kulam, they will begin to believe they are victims, and this could worsen their condition. And when this happens, relatives and friends will say, ?See? The patient?s condition is worsening so it has to be sorcery.?
A traditional healer might eventually be called in and he or she will ask the patient and her family if they might have offended someone. All of us?even the sweetest and most amiable?are likely to have inadvertently offended someone. People will remember encounters with some grumpy neighbor or officemate. With a 19-year-old girl, I am sure ?suspects? will include spurned and jilted boyfriends.
In my classes with health professionals and with medical students, I tell them we should let people conduct those rituals, as long as they don?t abandon professional help from doctors and ?Western? medicine. In the case of the 19-year-old girl, leaving TB untreated could mean the patient infecting others even as her own condition deteriorates.
I had to tell my housekeeper to warn the family that the girl could die of TB. Their response? She doesn?t have TB.
I want to be clear here and say that I do not believe in sorcery and sorcerers, much less the stereotype that Samar and Eastern Visayas (or even the entire Visayas) have more than a fair share of sorcerers. But we do need to develop cultural sensitivity in our health care system, which means tailoring our educational campaigns and medical services to the existing culture.
Sorcery is using the unexplainable to explain the unexplainable. But in the case of TB, we?re only seeing the surface with this barang attribution. The deeper problem here is the social stigma attached to TB. People still associate TB with being negligent, or even having a profligate lifestyle, men who drink too much for example. We need to educate people to understand that TB affects women and men of all ages; in fact, there are many children, even in upper-class families, who have TB but the medical establishment has contributed to the stigma and denial of TB by using euphemisms, telling mothers the child has ?weak lungs? or ?primary complex.?
We have to face up to the fact that TB is all around us, without passing judgment, without reinforcing myths and stigma. The sooner we admit to a TB problem, especially in our own families and communities, the easier it will be to control the disease.
Talk on elections
From sorcerers to politicians: Let me plug a talk I am giving today at the Yuchengco Museum in Makati at 6:30. I?ll be discussing Philippine elections as a cultural phenomenon, going beyond the usual guns, goons, gold and glitter analysis to look at how elections become opportunities to negotiate around feudal power and privilege. The talk is organized by the Museum Foundation of the Philippines, which is charging P200 for non-members, P100 for members and P50 for students. Call 404-2685 for more information and for reservations.