‘Snake-skinned’
IT WAS just another day in my life as a physician until she came in knocking at the door to my clinic, and, well, my life. She was an 18-year-old indigenous T’boli girl who had climbed down from her little community in the mountains in order to see me. She wore plain clothes, and had a pony tail. She had a roundish face hidden by strands of hair that crossed her face. She had nothing under her name except a confused but genuine smile, and her unusual skin—an intensely itchy, ornate pattern of serpent-like red lines and circles with extensive exfoliation from every inch of her scalp down to the very crevices of her toes. The extensive exfoliation made her look as if she had applied too much powder. I was shocked and rendered speechless by her sight.
This happened around my second year as a doctor in Kiamba, Sarangani Province. Until I met the girl, I had been eagerly looking for that one unique patient who would blow me away with a wonderful diagnosis. I looked far and wide, climbed mountains, attended to every case referred to me, investigated any outbreak reported, only to find the special case walking into my clinic in the end. Indeed, she had my full attention from the moment she walked in.
With the help of an interpreter, she shyly recounted the two long years she had borne her skin condition. It started when she was 16. She distinctly remembered having a very itchy and reddish circular mark on her leg. Over time, circles formed adjacent to it and expanded at a prodigious rate until all of her body was covered by the disease. When I saw her, every inch of her skin from her scalp down to her toes, with the exception of very few inches of skin, was affected. I knew I had my case, my “index” patient.
I made several referrals through the National Telehealth Center of the University of the Philippines Manila. The respondent from the Section of Dermatology suggested that it might be a “lovely case of Tinea imbricata or Tokelau ringworm,” a rare superficial fungal infection caused by the fungus Trichophyton concentricum, which can cause a skin pattern similar to the one I observed in my patient. The last reports of Tinea imbricata cases in the Philippines were in the 1990s and early 2000s involving patients who were mostly from indigenous tribes. It was left to me to prove that the girl was the first reported case of Tinea imbricata in Sarangani.
While I was still trying to muster scant resources and gather willing personnel to help me conduct an investigation, an old woman and her male sibling, also from the T’boli tribe, came into my clinic with the same serpentine skin. Both cases were less severe than the girl, but they had had it for at least 20 years. They told me their skin condition was called “blekis” or “bugis” and that it was rampant in many T’boli communities.
It occurred to me that the problem could be bigger than I have previously imagined, and because many were affected it could have implications on public health. But was this really Tinea imbricata?
With guidance from the Section of Dermatology and the help of my staff, I performed the necessary studies. Several weeks later, I was certain it was Tinea imbricata. My three patients—the girl, the old woman and her brother—became the first reported cases of Tinea imbricata in the province. I started them on oral anti-fungal medications and it produced very good results.
The findings and rumors that this was rampant in many other communities of Sarangani drew the attention of the Section of Dermatology some more. Together we planned an expedition to discover more cases. In just two days of searching we were able to discover 20 more T’bolis, from young children to old men and women, with blekis.
What I found most frustrating was that it was there all the time and it probably afflicted other indigenous groups in the Philippines but nobody had taken notice of it. Until now, in fact, nobody knows how many Filipinos have the disease, which is not even listed in most Philippine medical books. Which is quite ironic because the Philippines was one of the first countries in the world where this disease was first discovered in the 17th century.
The girl, the old woman and her male sibling had very sad stories to tell. Once the girl found out that she had the disease, she hid from her community. At an age when most girls are being wooed by men, she was concealing herself because she was ashamed of her condition.
The old woman had dreamed of working in the lowlands as a house help, but didn’t have the courage to move out of her little community. She once tried to apply for a job but she was quickly dismissed by her employer who was afraid she might spread the disease to his children.
Her brother was not subjected to a similar rejection, but he was concerned that he might pass on his disease to his wife and children.
Each of the other 20 new patients we discovered had his or her story to tell, too—from young children who dropped out of school because they were mocked and called “snake-skinned” to an entire family that was driven to leave in isolation because of shame. Many of them longed to socialize with other people, but their disease kept them from living normal lives. And there are surely many more who have remained undiscovered and untreated, and their stories unheard.
Just as poets have their muses, I have the girl who used to be snake-skinned. She gave me an experience of discovery within myself and the lives of others. Their stories are only the preface to the untold lives of the many indigenous Filipinos who live in places we know so little about and who need our attention because of an affliction that is probably not just skin-deep.
<em>Lemuel Benedict R. Non, MD, 28, was the Outstanding Doctor to the Barrio 2010, for Epidemiology and Research. A graduate of the University of the Philippines Manila, he placed eighth in the medical board examinations in 2008.</em>
