TB: A ‘boring emergency’

There is a disease that kills more Filipinos than dengue, measles and human immunodeficiency virus (HIV) combined — but hardly anyone is talking about it. Probably because it’s been around for so long, and has become “boring” for journalists and doctors alike. Probably because the disease itself has none of the dramatic signs of dengue, the highly visible symptoms of measles or the moral panic associated with HIV. Probably because most of its victims are poor, and the disease is therefore not a proximate concern for those of us who are in a position to make our voices heard.

But it does not make the numbers any less significant: Every day, it claims the lives of around 60 Filipinos.

The disease I speak of is tuberculosis or TB, which primarily affects the lungs but can also have extrapulmonary manifestations and, ominously, can present with virtually no symptoms. Despite the fact that TB nowadays is a largely treatable disease, it remains one of the leading causes of death in the country. And the country has the most number of TB cases — almost 1 million — in Southeast Asia.

Why has this been the case?

One of the major challenges in treating it is the nature of the disease itself. Because the mycobacteria that cause TB are hard to kill, it takes no less than six months of antibiotic treatment; anything less poses the risk of relapse, or worse, drug resistance. If even getting patients to adhere to a weeklong course of antibiotics is difficult, what more six months — plus side effects? The dearth of health human resources, facilities and even medicines further complicates treatment efforts, and so does the fact that despite the existence of Directly Observed Treatment, Short Course or DOTS centers, many can’t even afford to get there.

Other factors are cultural. The medical anthropologist Mark Nichter found in the 1990s that TB carried such a stigma that doctors instead told patients that they had “weak lungs,” and referred to the anti-TB drugs as “vitamins for the lungs.” People took this seriously, and used anti-TB drugs as a remedy for cough and colds — contributing to drug resistance. This stigma may have decreased today, but there remain many misconceptions about TB, including the view that you should only treat it when there are symptoms, and that its lengthy medication period can do more harm than good.

TB is actually not highly contagious, but those with weak immune systems and malnutrition are more likely to acquire it. Unsurprisingly, then, it is in marginalized communities such as urban slums where TB is widespread. Worryingly, there are now highly resistant strains (MDR TB, XDR TB) that at best require years of taking expensive (and often inaccessible) medicines to treat.

Many of our health officials are keenly aware of the burden of TB, but their efforts need more support. The Department of Health may still be feeling demoralized because of the Dengvaxia witch hunt, but both the vaccine scandal and the measles outbreak show that a strong and immediate response to a perceived health crisis is actually possible — from lawmakers, public health officials, the media and civil society alike. Without diminishing the need to act on other health concerns, I urge our government to take stronger action on a disease that is killing dozens of Filipinos every day.

Helpfully, Health Secretary Francisco Duque III has outlined the necessary steps in an address to the UN General Assembly. First, he identified the need for leadership—one that goes beyond rhetoric and acts on the social determinants of TB as well as the provisions of Republic Act No. 10767. Secondly, he called for the adoption of new technologies in diagnosis and treatment (e.g. rapid molecular assays)—an effort often undermined by the lack of medicines and supplies. Finally, he called for a stronger coordination between public and private health care providers, across all levels of care, for better tracking of cases.

Taking these steps will require the cooperation of various sectors. But, above all, we need political will from the highest levels of government—including President Duterte himself. To use Duque’s own words, we cannot afford to do “business as usual.” Boring it may be, yet given its grave human toll, TB cannot be treated as anything less than a national emergency.

glasco@inquirer.com.ph