TB and social justice

Are we treating our patients only to return them to the conditions that have made them sick in the first place?

As a doctor to the barrio in Misamis Oriental, I sometimes grapple with this question — especially whenever I interact with my patients with serious conditions like tuberculosis (TB).

Consider the case of Mang Roger, in his mid-50s, a father of six. For over a year, Mang Roger had experienced bouts of coughing, coupled with night sweats and occasional shortness of breath. Because he had to work in a coconut plantation on a day-to-day basis, and because his barangay was so far away from the clinic, he did not consult with a doctor, even as his cough worsened, and even as the worsening cough led to his being fired from his job.

Finally, he went to our health center, and after some examinations, I diagnosed him with multidrug resistant tuberculosis — a form of TB that does not respond to the regular six-month course of treatment.

It would take two years of daily injections, to be conducted by the rural midwife, for him to have a shot at survival. It would require daily trips to the clinic — the cost and effort of which are sure to exact a heavy toll on his family.

Mang Roger is typical of the patients I encounter. For them, cough is so common that it is seen as normal — or just an inevitable consequence of the physically exhausting work they do. Some of them are unaware that something as seemingly harmless as cough can be a symptom of debilitating diseases like tuberculosis or chronic obstructive pulmonary disease. Even when they are actually taking it seriously and contemplating seeing a doctor, they end up not doing so, because to skip one day of work can mean having no food on their table.

Thus, it is not uncommon for patients to eventually succumb to these serious conditions; for them to come to our clinic too late for any intervention to save their lives. Their diseases may be the “cause of death” I end up writing in their death certificate, but I know that various aspects of their precarious lives actually led to their deaths.

For instance, the insufficiency of the food they eat, both in quality and quantity, which leads to a weakened immune system, which in turn predisposes them to diseases like TB—and holds back their recovery even with treatment.

Or the inaccessibility of the health clinics, their sheer distance — and the fact that even a P20 habal-habal fare is better spent on half a kilo of rice.

There is also the dearth of health literacy, which includes a lack of knowledge about the dangers of self-medication, especially for diseases like TB for which drug resistance can have fatal consequences. Misinformation leads to stigma, which further isolates patients from the help they need.

Finally, and oftentimes most importantly, there’s the sheer lack of funds to act on whatever health knowledge they have. Like Mang Roger, many of our patients know they need help, but the need to work keeps them from seeking help.

Beyond these “social determinants” on the side of the patient, we also have shortcomings in health service delivery. Because we lack the laboratory and the personnel to diagnose TB at the primary care facility level, we need to refer them to a nearby city, making it even harder for patients to get to the treatment stage.

Health — which is managed by local governments under a “devolved system” — is not always prioritized by mayors, leaving health centers understaffed and understocked with vital medications. The recently passed Universal Health Care Act appears to have been crafted to respond to these problems, but it remains to be seen if it will make a difference.

What is clear to me is that we will not be able to eradicate TB and other serious health problems unless we go beyond our clinics and consider what goes on in our patients’ lives, what prevents them from consulting doctors and taking medications, and what forms of knowledge, attitudes and practices impact their health.

Ultimately, this will implicate poverty, but if diseases like TB are socially determined, then we have to accept that their medicine is social justice.

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Terence Lincolne Kua, 26, is a graduate of the UP College of Medicine and currently serves as a rural health physician in Medina, Misamis Oriental, as part of the Doctors to the Barrios Program of the Department of Health.