Plague was creeping through the alleys of Manila. The morgue was piled high with the bodies of cholera dead. Forty thousand unvaccinated were uselessly slaughtered each year by smallpox. Tuberculosis, unconsidered and unfeared, was responsible for fifty thousand deaths annually. The beriberi victims were numbered in the tens of thousands. Every other child died before its first birthday; the Philippines had the unenviable distinction of having the highest infant mortality rate in the world.”
That was Director of Health Dr. Victor Heiser, an American public health pioneer, describing the health conditions at the start of the American occupation of the Philippines in the early 1900s. Four original murals on Philippine medical history by National Artist Botong Francisco, including one on the American era, used to be displayed at the lobby of the Philippine General Hospital. They have been replaced with facsimiles (the original ones are now in the National Museum).
The Philippines is no stranger to public health problems. As early as the 16th century, a Franciscan missionary founded the Hospital de los Indios Naturales—later renamed the San Lazaro Hospital after the patron saint of lepers, the beggar Lazarus—when Japan sent more than a hundred lepers to Manila who were confined in that hospital. Today, the hospital is known for its expertise in infectious diseases.
As medical students many years ago, we were required to complete courses in public health like epidemiology, or the frequency and patterns of disease prevalence in large populations—a subject not really interesting to us then. Clinical subjects like surgery and internal medicine were more appealing. However, in today’s COVID-19-saturated media, public health issues and infectious diseases have taken center stage. The public health experts are also medical detectives, tracking disease origins and contributing to policymaking on a national scale.
Consider polio, for example. The Pulitzer Prize-winning American historian Richard Rhodes wrote: “One day, a headache, an hour later paralyzed. How far up your spine the virus traveled determined whether you could walk, or breathe. Parents waited every summer to see if it would strike. One case turned up and then another. The count began to climb.” Written reports during the 1916 polio epidemic in New York City described thousands fleeing the city in panic. Movie theaters and swimming pools were closed, public gatherings were canceled, and the identities of confirmed polio cases were published in the press, their houses marked with placards. All kinds of treatments were proposed, some bordering on quackery—until effective polio vaccines eradicated the disease.
Fast forward a hundred years later when air travel easily mobilizes people, social media spreads news, real or fake, at the speed of a click, and densely populated cities become petri dishes of contagion. Public health has become interlinked with national security and governance, the economy, and even human rights. How a country responds to epidemics will determine the outcome. The Philippines, for instance, is one of the most disaster-prone countries in the world, and with natural disasters follows the inevitability of epidemics. Infectious disease surveillance is just one aspect of the multi-faceted approach needed in disaster planning.
In the current pandemic, sharing clinical experience among scientists and physicians of many countries as published in medical journals is a remarkable example of international cooperation, of which the Philippines can be part. As the American journalist I. F. Stone said: “Either we learn how to live together or we die together.”
There is this anecdote about Albert Einstein, who reportedly gave the exact examination he gave his students the previous year, and when confronted with this, replied: The answers have changed.
The answers on public health responses will certainly change; the world has become more complex since Dr. Heiser’s report 100 years ago. Epidemics test the public health system and infrastructure preparedness of a country, and COVID-19 is a wake-up call. Unfortunately, like SARS and MERS before it, it won’t be the last.
—————-
Jose Luis J. Dañguilan, MD, a thoracic surgeon, is the former executive director of the Lung Center of the Philippines.