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Our TB problem

/ 12:06 AM September 05, 2014

Older Filipinos will remember those Christmas seals that were once required, in addition to postage stamps, to mail a letter or package. I haven’t seen those seals for years, but that’s because I now rarely get “snail mail” delivered by the Post Office. Everything’s by e-mail now, or by courier.

I miss those Christmas seals because they were meant to raise funds for the Philippine Tuberculosis Society (PTS), which at one time was at the forefront of TB prevention and control. The seals were mainly decorative, with a Christmas theme, but “TB” appeared prominently to remind people of a serious public health problem.

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The use of these seals was borrowed from the United States, which had a serious TB problem until the 1950s. While researching on these anti-TB seals I even found, on YouTube, an old commercial featuring John Wayne comparing his own rough-and-tumble life as an action star with the struggles of Americans with TB. He then went on to say that every five minutes, an American was being infected with TB, and how important it was to buy Christmas seals and support efforts to control the disease.

TB was a serious public threat worldwide; it was referred to as the “white plague.” Our own President Manuel Quezon died from TB in 1944, which was why years later, when the PTS was established, it set up a Quezon Institute (or QI) to care for patients with TB.

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The Quezon connection also explains why August, his birth month, is the time when TB is remembered. Alas, like the celebrations around Quezon and the national language, TB disappears from public consciousness after the month is over.

Global emergency

In developed countries, TB came under control in the late 1950s through a combination of treatment with potent drugs and, perhaps more importantly, an improvement of living conditions, particularly by reducing overcrowded housing and, simply, public health education such as covering the mouth when coughing and not spitting.

TB was eventually forgotten in the developed world, together with research for its prevention and cure, even as the disease continued to rage in developing countries. TB was especially problematic in the Philippines, for years refusing to be dislodged as the third leading cause of death in the country.

Then the HIV/AIDS epidemic came around. HIV infections slowly destroy the body’s immune systems, making the patient more prone to so-called opportunistic infections. One of the most common of these infections was TB.

Suddenly TB was back in the headlines, with the developed countries feeling the threat of a resurgence. In 1994, the World Health Organization declared TB a global emergency and issued a world report on the disease, with a Filipino farmer on the cover.

The TB problem in the Philippines was more than a biomedical issue. Poverty was clearly one of the reasons the disease was spreading so quickly in slum areas. But I’ve always worried about tagging TB as a disease of the poor because many other developing countries did come to control it.

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Our TB problem was serious because we never considered it “our” problem with shared responsibilities.  It was always someone else’s problem. Even the doctors were divided. The government had its own TB control program, funded mainly by those Christmas seals, to deploy mobile X-ray units, and to put TB patients in QI.

But even QI contributed to making TB a disease of “other people.” QI’s buildings were almost foreboding. I remember how, when I was a child, my father would order everyone in the car to stop breathing for the few seconds that he drove past QI, so fearful was he of TB germs and—unspoken, of course—of the idea that these were TB germs of poor people in there.

But TB also afflicted middle- and high-income families; it was quietly treated as “primary complex” and “weak lungs” by private pediatricians. I have to say maybe even “overtreated,” because a prolonged cough was assumed to be a TB infection, with anti-TB drugs automatically prescribed as “vitamins for the lungs.” Those anti-TB drugs were also given out indiscriminately in medical missions usually organized by politicians as elections drew near.

A growling CAT

After the World Health Organization declared TB a global emergency, money came pouring back into TB care, particularly for the DOTS (or direct observed treatment short-term), where a patient is treated for free for six months, under strict medical supervision.

Fortunately, too, the private and public sectors had come together to fight TB, forming a Philippine Coalition Against Tuberculosis or PhilCAT in 1993. TB was no longer just for chest physicians but also for pediatricians, family practice, microbiologists, religious orders, universities.

As a PhilCAT 20th-anniversary publication boasts, this CAT does not purr, but growls.

I sure hope so. TB has slowly slid down the chart of leading causes of death, from third to sixth place. But PhilCAT estimates there are still more than 60 Filipinos dying each day from TB.

These deaths happen because TB is still someone else’s disease. I’d like to dispel the idea that TB only happens to the poor. In one of those eerie coincidences, last Aug. 14 when I had to deliver the keynote speech at the PhilCAT annual convention, I dropped by my office to sign some papers before heading to the PhilCAT event. Among the papers were several vouchers for reimbursement of medical expenses. One of the requests stood out: It was for hospitalization because of MDR (or multidrug-resistant) TB.

A few years ago I heard of a young faculty member who had died of MDR TB. There was a bit of black humor as people joked that the faculty salaries at UP were at poverty level, which made us vulnerable to TB.

Seriously, TB is spreading rapidly again because of improper treatment, such as using anti-TB drugs when there is no TB, or not completing the six months of therapy.  This has resulted in the emergence of TB strains resistant to most of the drugs available. There is now a program for such MDR cases, but it requires two years of continuous treatment.  Even if the drugs are free, the drop-out rate is high.

TB will require rethinking many of our old strategies. Genetics research will be vital because it will not be enough to simply identify TB germs in a patient; instead, we have new but still expensive genetics-based tests that will establish if the infection is from one of the resistant strains.

Genetics research will also identify how various strains are spreading. One local genomics study has an ominous finding that many TB infections are being acquired outside the household. It’s anybody’s guess where this is happening, but can include the work place, or crowded transport vehicles. (Given a choice, I’d take a jeep and risk urban air pollutants rather than a closed SUV with people coughing away without covering their mouth.)

There’s so much more that we need to learn about TB, but even as medical research continues, even without those Christmas seals, we have to think of it as “our” problem and not just someone else’s. Robin Padilla for an anti-spitting and covering-your-mouth-as you-cough campaign, perhaps?

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E-mail: [email protected]

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TAGS: HIV infections, HIV/AIDS epidemic, immune systems, Philippine Tuberculosis Society, PTS, public health problem, TB prevention and control, Tuberculosis, World Health Organization
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